Canadian Clinical Practice Guidelines for Management of Anxiety, PTSD and OCD: Part 1 (Anxiety) Flashcards
what is the lifetime prevalence of anxiety disorders
31% estimated (higher than mood or SUDs)
anxiety disorders are associated with increased risk of developing what other comorbid disorder
MDD
about what % of those with anxiety and related disorders are untreated
estimated 40%
what is the increased risk of suicide associated with anxiety disorders
1.7-2.5x risk of suicide attempts
*unclear if moderated by gender
*increased risk of suicide attempt in PTSD, GAD and panic disoder even in absence of comorbid mood disorder (though presence of comorbid mood disorder greatly increases risk)
*must explicitly evaluate suicide risk in anxiety patients
family history of anxiety or mood disorders offers what prognostic information for those with anxiety disorders
more recurrent course
greater impairment
greater service use
list common risk factors in patients with anxiety and related disorders
family history of anxiety
personal history of anxiety or mood disorder
childhood stressful life events or trauma
being female
chronic medical illness
behavioural inhibition
*loneliness, low education, adverse parenting, chronic somatic illness may increase lifetime risk of diagnosis of anxiety
what % of those with anxiety and related disorders also have another anxiety disorder
50%
often substance use or mood disorder
what medical illnesses are more common in those with anxiety and related disorders compared to those without anxiety and related disorders
HTN
other CV conditons
GI disease
arthritis
thyroid disease
respiratory disease
migraine headaches
allergic conditions
what should be included in baseline assessment in someone with suspected anxiety and related disorders
ROS
Rx meds and OTC meds
alcohol use
illicit drug use
caffeine intake
+evaluate anxiety symptoms and functioning
what should ALL patients with anxiety and related disorders receive in terms of treatment
education about their disorder
efficacy and tolerability of treatment choices
aggravating factors
signs of relapse
information in self help materials ie books
what are some of the factors that might determine whether to pursue pharmacological or psychological treatment for anxiety and related disorders
patient preference and motivation
ability of patient to engage in the treatment
severity of illness
clinician skills and experience
availability of psychological treatments
patients prior response to treatment
presence of comorbid medical or psychiatric disorders
how does efficacy differ between pharmacotherapy and psychological treatment for anxiety and related disorders
about equivalent efficacy for most anxiety and related disorders
results of combo therapy vary between disorders and results have been comflicting
does the current evidence support routine combination of CBT and pharmacotherapy as initial treatment?
no not currently for routine treatment
when might benzos be useful in treatment of anxiety and related disorders
ADJUNCTIVE therapy
EARLY in treatment
especially for acute anxiety or agitation or to help patients in times of acute crises or while waiting for onset of adequate efficacy of SSRIs or other antidepressants
*should be restricted to short term use and generally dosed REGULARLY rather than as needed due to concerns about possible dependency, sedation, cognitive impairment and other SEs
what are the most common SEs with SSRIs, SNRIs
headache
sexual dysfunction
insomnia
GI upset
irritability
tremor
drowsiness
increased anxiety
weight gain
which SEs of SSRIs, SNRIs may persist throughout treatment
weight gain and sexual dysfunction
what are the most common SEs with benzos
sedation
fatigue
ataxia
slurred speech
memory impairment
weakness
*associated with withdrawal reactions, rebound and dependence (risk greater with short and medium rather than long acting formulations)
can benzos cause cognitive impairment after discontinuation
yes–> has been reported persisting beyond cessation of therapy
side effects of buspirone
dizziness
drowsiness
nausea
how long should pharmacotherapy continue for most patients with anxiety and related disorders
at least 12-24 months
(longer term therapy associated with continued symptomatic improvement and the prevention of relapse)
how should medications be titrated in anxiety and related disorders
initiated at low doses
titrated to recommended dosage range at 1-2 week intervals over 4-6 weeks
once therapeutic dose achieved, improvement seen in about 4-8 weeks
what is a scale to measure the impact of an illness on functioning
Sheehan disability scale
or
SF-36
what is the lifestime estimated prevalence of panic attacks
28.3%
what % of the general public will have a panic attack without ever developing any identifiable psychopathology
about 8-10%
rates of panic disorder/agoraphobia are higher in which populations
women
middle aged
widowed-divorced
low income
**NO difference in urban vs rural setting
what psychological approaches have been shown to be the most effective in treating panic disorder
strategies involving exposures
does CBT or pharmacotherapy seem to be the most effective for panic disorder
CBT was “significantly favored” over medications for the treatment of panic disorder in a meta analysis
*exposure + combinations of exposure, cognitive restructuring and other CBT techniques has the most consistent evidence
which was more effective for panic disorder, CBT that included interoceptive exposure or relaxation therapy
CBT that included interoceptive exposure
name two factors that improved the effectiveness of psychological treatments for panic disorder
inclusion of homework
follow up program
how do minimal intervention formats I.e self help books, internet based CBT, compare in efficacy compared to other psychological treatments for panic disorder
more effective than wait list or relaxation controls
as effective as face to face CBT
how long are CBT protocols for panic disorder
usually 12-14 weeks but shorter 6-7 session programs have been shown to be as effective
list predictors of decreased response to CBT for panic disorder
severity of panic disorder
strength of blood/injury fears
earlier age of onset of initial symptoms
comorbid social anxieties
degree of agoraphobic avoidance
name two key process variables in CBT therapy for panic disorder
changes in beliefs and changes in avoidance behaviours
does EMDR appear to be effective for panic disorder
EMDR does not seem to be more effective as the same strategy without the eye movement component
in panic disorder, is combo CBT + med therapy superior?
seems to be better than either CBT or meds alone during acute treatment phase and while meds were continued
what should be considered first line treatment for panic disorder
CBT alone or CBT + meds
is there benefit to CBT + benzos for treatment of panic disorder
does not seem to be (compared with psychotherapy or meds alone)
*followup suggests combo might be WORSE than behaviour therapy alone
what has been shown to be helpful in facilitating benzo discontinuation in those with panic disorder
CBT
how long were benefits of CBT maintained for those with panic disorder
up to 3 years
(one study shows 62% remained in remission after 10 years(
list first line meds for treatment of panic disorder
Call Every Familiar Fun Person Said Veronica
*SSRIs/SNRIs
Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
Venlafaxine XR
list second line meds for treatment of panic disorder
All Cats Can Dance In Lazy Morning Rounds
*lots of benzos in this list
Alprazolam
Clomipramine
Clonazepam
Diazepam
Imipramine
Lorazepam
Mirtazapine
Reboxetine
list third line meds for treatment of panic disorder
*the random drugs, including mood stabilizers, anticonvulsants and antipsychotics
Buproprion SR
divlaproex
duloxetine
gabapentin
levetiracetam
milnacipran
moclobemide
olanzapine
phenelzine
quetiapine
risperidone
tranylcypromine
what medications are NOT recommended in panic disorder
buspirone
propanolol
tiagabine
trazodone
are there any first line adjunctive therapies for panic disorder
no
list two second line adjunctive therapies for panic disorder
alprazolam, clonazepam
list five third line adjunctive therapies for panic disorder
aripiprazole
divalproex
olanzapine
pindolol
risperidone
what benefits have been shown from SSRIs in the treatment of panic disorder
panic symptoms
agoraphobic avoidance
depressive symptomatology
general anxiety
how does efficacy compare between TCAs and SSRIs in the treatment of panic disorder
similar efficacy but TCAs tend to be not as well tolerated and have higher discontinuation rates
in which patients with panic disorder might you consider moclobemide and why
treatment resistant patients who are severely ill as while results for efficacy mixed for panic disorder, shows significant efficacy in severely ill patients
how effective is risperidone at treating panic disorder
RCT showing risperidone having similar efficacy as paroxetine to treat panic disorder
list the 3 AAPs with evidence (open label) for treating panic disorder
olanzapine
risperidone
quetiapine
why might you consider using alprazolam or clonazepam short term at initiation of SSRI therapy for panic disorder
can lead to a more rapid response
use for less than 8 weeks including taper of the benzo
what is the RCT data for pindolol in the treatment of panic disorder
adjunctive
when combined with fluoxetine in patients with treatment resistant panic disorder, associated with significant improvement in symptoms compared with fluoxetine + placebo
is there evidence for neurostimulation treatment for panic disorder
open label/level 3/4 evidence
- REAC (radioeelctric asymmetric conveyor)–> efficacy for panic sx and agoraphobia
- rTMS in patients with comorbid MDD but results mixed
what are some alternative therapies for panic disorder
- capnometry assisted respiratory training –> was as effective as cognitive training in reducing symptom severity and panic related cognitions and improving perceived control
(results mixed) - exercise groups seemed to do better than relaxation groups but not significant
–> acute aerobic exercise found to reduce anxiety as well as panic attack frequency and intensity compared to quiet rest condition
what approached to treatment for panic disorder are supported by the evidence
pharmacotherapy–> begin with first line agent. if inadequate response or agent not tolerated, tx should be switched to another first line agent before trying second line agent
CBT alone
combo
all can be initial treatments for panic disorder
CBT may not be sufficient in some patients i.e SI, rapidly worsening agoraphobia, moderate to severe MDD etc
who is considered to have treatment refractory panic disorder
those who do not respond to first or second line agents
*in this case, reassess dx and consider comorbid medical and psych conditions that may be affecting tx
then can consider third line agents and adjunctive therapies, as well as biological and alternative treatments
what is the treatment of choice for specific phobias
psychosocial interventions–> particularly EXPOSURE BASED treatments
in vivo exposures better at posttreatment but not at follow up (compared to other types of effective exposures like virtual reality or imaginal)
list factors that have shown to make exposure based therapy for specific phobias more effective
sessions are grouped closely together
exposure is prolonged
exposure is real (vs imagined)
exposure is provided in multiple settings
there is some degree of therapist involvement
*one session can be effective but greater number of sessions predicted more favorable outcomes
for specific phobias treatment, is flooding or gradual exposure more effective
no evidence either way but progressive exposures are more tolerable to patients generally
are psychological treatment outcomes for specific phobias moderated by the type of specific phobia?
no–> but studies have suggested that certain types may respond more favorably to specific types of treatment
what should be combined with exposure therapy for those with blood/injection/needle phobia
muscle tension exercises (applied tension) designed to prevent fainting
use of stress reducing medical devices like decorated butterfly needles and syringes (for both adults and kids)
what type of psychosocial intervention is recommended for fear of flying
group CBT
computer generated VR exposure
(bibliotherapy less effective)
list some specific phobias for which virtual reality exposures have evidence of efficacy
fear of flying
fear of heights
claustrophobia
arachnophobia
what compound has been speculated to improve extinction of fear in patients with specific phobias undergoing behavioural exposure therapy
d-cycloserine
–> RCT combining with VRE for acrophobia showed significantly larger reductions in symptoms compared to VRE alone (but other results mixed)
adjunctive cortisol
–> ?cortisol may facilitate the extinction of phobic fear at follow up
what is d-cycloserine
a partial agonist at the NMDA receptor
speculated to improve extinction of fear in patient with specific phobias undergoing behavioural exposure therapy
what is yohimbine
yohimbine hydrochloride = noradrenaline agonist
?facilitate fear extinction as enhanced emotional memory may be stimulated through elevated noradrenaline levels
not good data from RCTs
is there a large role for pharmacotherapy in the treatment of specific phobias
no–> “minimal role” (largely due to lack of research)
mainstay is CBT + exposures
name 4 antidepressants that have some (if small) evidence for benefit in treating specific phobias
paroxetine
escitalopram
fluoxetine (flying phobias)
fluvoxamine (storm phobia)
is there evidence for adjunctive benzos combined with exposure therapy for specific phobias
no
is pharmacotherapy generally a recommendation for treatment for specific phobias
no not really–> exposure based techniques are highly effective
what is the estimated lifetime prevalence of social anxiety disorder
8-12% internationally
(higher rates in developed vs developing countries)
what is the mean age of onset of social anxiety disorder
12 years old
what is the typical course of social anxiety disorder
chronic and unremitting
how does social anxiety disorder affect disability
canadians with social anxiety disorder were twice as likely to report at least one disability day in the last two weeks compared to those without it
list psychiatric conditions commoly comorbid with social anxiety disorder
MDD and other anxiety disorders = highest rates
avoidant PD
body dysmorphic disorder
SUD
ADHD
schizophrenia
what is considered the gold standard nonpharmacological treatment for social anxiety disorder
CBT
what are the main cognitive techniques involved in CBT for social anxiety disorder
restructuring and challenging maladaptive thoughts
behavioural component –> typically in form of exposure therapy
how does efficacy compare between CBT and pharmacotherapy for social anxiety disorder
similar
?changes persist long with CBT
is videotaped feedback helpful as enhancement for exposure based treatment for social anxiety disorder
no
what type of CBT was found to be as effective as standard CBT but also improved relationship satisfaction and social approach behaviours
CBT focused in interpersonal behaviour
is there evidence to support IPT in social anxiety disorder
conflicting evidence
likely more effective than wait list control but less effective than CBT
which has more long term benefit for treatment of social anxiety disorder, psychotherapy or pharmacotherapy
seems to be psychotherapy
is there good evidence for pharmacological interventions for social anxiety disorder
yes-> SSRIs, SNRIs, anticonvulsants, and benzos
list first line agents for treatment of social anxiety disorder + mnemonic
Every Fungus Packs Pretty Sweet Value
Escitalopram
Fluvoxamine and fluvoxamine CR
Paroxetine and paroxetine CR
Pregabalin
Sertraline
Venlafaxine XR
l
list second line agents for social anxiety disorder + mnemonic
All Bros Can Carry Giant Pigs
Alprazolam
Bromazepam
Citalopram
Clonazepam
Gabapentin
Phenelzine
list third line agents for social anxiety disorder
atomoxetine
buproprion SR
clomipramine
divalproex
duoxetine
fluoxetine
mirtazapine
moclobemide
olanzapine
selegiline
tiagabine
topiramate
list two medications that are NOT recommended as adjunctive therapy for social anxiety disorder
clonazepam
pindolol
why is fluoxetine third line for social anxiety disorder
there are NEGATIVE trials of fluoxetine in social anxiety disorder suggesting less effective than other SSRIs
are there any first line adjunctive therapies for social anxiety disorder
no–> only third line
list the (third line) adjunctive therapies for social anxiety disorder
abilify
buspirone
paroxetine
risperidone
list medications NOT recommended in the treatment of social anxiety disorder
atenolol
buspirone
imipramine
keppra
propanolol
quetiapine
*beta blockers can be useful for performance but not generally
what doses of pregabalin have been shown to be effective for social anxiety disorder
higher doses (i.e 600mg/day) rather than lower doses (150mg/day) is effective
*unclear how efficacy of pregabalin compares to SSRIs
how do benzos compare to SSRIs in efficacy for treating social anxiety disorder
similar efficacy but benzos are second line due to lack of action on other possible comobidities with social anxiety disorder + potential for abuse and dependence in those with history of SUDs
why is phenelzine restricted to second line recommendation social anxiety disorder despite level 1 evidence for efficacy
due to concerns around dietary restrictions, drug interactions and potential for hypertensive crisis
is keppra recommended in social anxiety disorder
no
is quetiapine recommended for treatment of social anxiety disorder
no
is buspirone recommended for treatment of social anxiety disorder
no
is risperidone recommended for treatment of social anxiety disorder
third line
is fluoxetine recommended for treatment of social anxiety disorder
third line
is fluvoxamine recommended for treatment of. social anxiety disorder
first line
is citalopram recommended for treatment of social anxiety disorder
second line
is escitalopram recommended for treatment of social anxiety disorder
first line
is paroxetine recommended for treatment of social anxiety disorder
first line
is sertraline recommended for social anxiety disorder
first line
is gabapentin recommended for social anxiety disorder
second line
is phenelzine recommended for social anxiety disorder
second line
is there generally long term therapy for specific phobias
no not generally
is there indication for long term medication treatment in social anxiety disorder
yes–> highly significant reduction in relapse rates with continued SSRI treatment compared to placebo over 3-6 months
NNT = 3.57
(pregabalin also has evidence in reducing relapse rates)
name a biological/neurostim therapy that has shown evidence for efficacy in social anxiety disorder
neuro psycho physical optimization-radio electric asymmetric conveyor (NPPO-REAC)
is a brain stimulation technique
*was as effective as sertraline for tx of social anxiety disorder
is st johns wort recommended for treatment of social anxiety disorder
no
failed to demonstrate superiority over placebo
has adding pharmacotherapy to CBT been shown to increase the benefits of CBT in the treatment of social anxiety disorder
no
what is the estimated lifetime prevalence of GAD
about 6%
in what population is GAD more frequenct
caucasians
what is the age of onset of GAD
may be bimodal
median age is 31 years and mean age is 32.7 years
what is the usual age of onset for GAD in kids and teens
10-14 years
what % of those with GAD report painful physical symptoms
60-94%
main reason for presentation in primary care in 72% of cases
what medical syndromes have elevated risk in those with GAD
pain syndromes
HTN
CV and gastro conditions
list problems that have been specifically identified among those with GAD that have become part of evidence based CBT protocols for GAD
intolerance of uncertainty
poor problem solving confidence
positive and negative metacognitive beliefs about the function or utility of worry
list psychotherapeutic interventions that have evidence in GAD treatment
Acceptance based behaviour therapy
meta cognitive therapy
CBT targeting intolerance of uncertainty
adjunctive MBCT
*meta analyses clearly support CBT
is psychodynamic therapy helpful for GAD
some studies–> short term psychodynamic is as effective as CBT for anxiety scores but CBT was better for worry and depression
other studies–> no significant differences between brief psychodynamic, pharmacotherapy or combo
what are the benefits of adding pre treatment motivational interviewing as an adjunct to CBT for GAD
helps reduce resistance to therapy
improves homework compliance
improves worry outcomes
is psychotherapy, pharmacotherapy or combo best for treatment of GAD
meta analysis–> combo is better than CBT alone at post treatment but not as 6 month follow up (it was CBT + clonazepam or + buspirone vs CBT alone)
is there evidence to support the routine combo of CBT + pharmacotherapy in GAD
no–> but as in other anxiety disorders, when patients do not benefit from CBT or have limited response, trial of pharmacotherapy is advisable (and vice versa)
are the benefits of CBT maintained for those with GAD
yes–> seem to be maintained at 1-3 years
first line pharmacotherapy for GAD
Anxious People Pray So Voraciously Every Day
Agomelatine
Paroxetine + paroxetine CR
Pregabalin
Sertraline
Venlafaxine XR
Escitalopram
Duloxetine
second line pharmacotherapy for GAD
Anyone Buying Biscuits Begins Quietly Hiding Desserts In Locked Vehicle
Alprazolam
Bromazepam
Buproprion XL
Buspirone
Quetiapine
Hydroxyzine
Diazepam
Imipramine
Lorazepam
Vortioxetine
third line pharmacotherapy for GAD
citalopram
divalproex chrono
fluoxetine
mirtazapine
trazodone
*these antidepressants are third line as only have open label studies or case series but did demonstrate efficacy
*trazodone was as effective as diazepam
name a second line adjunctive agent for treatment of GAD
pregabalin
name 4 third line adjunctive agents for treatment of GAD
aripiprazole
olanzapine
quetiapine/quetiapine XR
risperidone
name an agent that is NOT recommended as an adjunctive agent for GAD
ziprasidone
name 3 medications that are NOT recommended for treatment of GAD
beta blockers (i.e propanolol)
pexacerfont
tiagabine
among the classes of meds in the second line agent group for GAD, which medications would generally be considered “first” among the second line agents
the benzodiazepines, except where there is a risk of substance use
(buproprion would likely be reserved for later)
in which patients would you consider using quetiapine XR for treatment of GAD
patients who cannot be given antidepressants or benzos
*does have good efficacy though, its just the concerns about metabolics due to being an AAP
how does efficacy compare between pregabalin and benzos in treatment of GAD
similar (pregabalin as effective as benzos)
(and was more effective than venlafaxine in one trial and equally efficacious in another)
buproprion XL wa shown to be as effective as which SSRI for treatment of GAD
escitalopram (a first line option)
what is the evidence for use of vortioxetine in GAD
second line recommendation
level 1, conflicting evidence
one trial showed benefit one did not but ?due to difference in recruitment in the studies?
how does quetiapine compare in terms of efficacy to antidepressants for GAD
equally efficacious but lead to more weight gain and sedation and had higher dropout rates
what evidence is there for adjunctive risperidone in GAD
limited–> only showed benefit over placebo in those with moderate to severe residual symptoms
what neurostimulation therapy may be beneficial for treatment of GAD
rTMS as monotherapy or adjunctive to SSRI
list 4 herbal preparations that may have efficacy in GAD
silexan (lavender oil) + galphemia glauca extract –> similar to lorazepam in efficacy
passion flower–> as effective as benzos
valerian
*preparations are poorly standardized and thus difficult to recommend
name a lifestyle intervention that has evidence for improving GAD symptoms
weightlifting or aerobic exercise
*significant symptomatic improvements compared to wait list condition
is there evidence for bright light therapy for GAD
no (when compared with placebo) and thus is not recommended
is CBT first line for GAD
yes, is an effective FIRST LINE option for GAD and is AS EFFECTIVE as pharmacotherapy
