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5. Anxiety Disorders > Canadian Clinical Practice Guidelines for Management of Anxiety, PTSD and OCD: Part 1 (Anxiety) > Flashcards

Canadian Clinical Practice Guidelines for Management of Anxiety, PTSD and OCD: Part 1 (Anxiety) Flashcards

1
Q

what is the lifetime prevalence of anxiety disorders

A

31% estimated (higher than mood or SUDs)

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2
Q

anxiety disorders are associated with increased risk of developing what other comorbid disorder

A

MDD

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3
Q

about what % of those with anxiety and related disorders are untreated

A

estimated 40%

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4
Q

what is the increased risk of suicide associated with anxiety disorders

A

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

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5
Q

family history of anxiety or mood disorders offers what prognostic information for those with anxiety disorders

A

more recurrent course

greater impairment

greater service use

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6
Q

list common risk factors in patients with anxiety and related disorders

A

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

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7
Q

what % of those with anxiety and related disorders also have another anxiety disorder

A

50%

often substance use or mood disorder

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8
Q

what medical illnesses are more common in those with anxiety and related disorders compared to those without anxiety and related disorders

A

HTN

other CV conditons

GI disease

arthritis

thyroid disease

respiratory disease

migraine headaches

allergic conditions

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9
Q

what should be included in baseline assessment in someone with suspected anxiety and related disorders

A

ROS

Rx meds and OTC meds

alcohol use

illicit drug use

caffeine intake

+evaluate anxiety symptoms and functioning

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10
Q

what should ALL patients with anxiety and related disorders receive in terms of treatment

A

education about their disorder

efficacy and tolerability of treatment choices

aggravating factors

signs of relapse

information in self help materials ie books

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11
Q

what are some of the factors that might determine whether to pursue pharmacological or psychological treatment for anxiety and related disorders

A

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

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12
Q

how does efficacy differ between pharmacotherapy and psychological treatment for anxiety and related disorders

A

about equivalent efficacy for most anxiety and related disorders

results of combo therapy vary between disorders and results have been comflicting

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13
Q

does the current evidence support routine combination of CBT and pharmacotherapy as initial treatment?

A

no not currently for routine treatment

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14
Q

when might benzos be useful in treatment of anxiety and related disorders

A

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

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15
Q

what are the most common SEs with SSRIs, SNRIs

A

headache

sexual dysfunction

insomnia

GI upset

irritability

tremor

drowsiness

increased anxiety

weight gain

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16
Q

which SEs of SSRIs, SNRIs may persist throughout treatment

A

weight gain and sexual dysfunction

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17
Q

what are the most common SEs with benzos

A

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)

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18
Q

can benzos cause cognitive impairment after discontinuation

A

yes–> has been reported persisting beyond cessation of therapy

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19
Q

side effects of buspirone

A

dizziness

drowsiness

nausea

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20
Q

how long should pharmacotherapy continue for most patients with anxiety and related disorders

A

at least 12-24 months

(longer term therapy associated with continued symptomatic improvement and the prevention of relapse)

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21
Q

how should medications be titrated in anxiety and related disorders

A

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

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22
Q

what is a scale to measure the impact of an illness on functioning

A

Sheehan disability scale

or

SF-36

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23
Q

what is the lifestime estimated prevalence of panic attacks

A

28.3%

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24
Q

what % of the general public will have a panic attack without ever developing any identifiable psychopathology

A

about 8-10%

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25
Q

rates of panic disorder/agoraphobia are higher in which populations

A

women

middle aged

widowed-divorced

low income

**NO difference in urban vs rural setting

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26
Q

what psychological approaches have been shown to be the most effective in treating panic disorder

A

strategies involving exposures

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27
Q

does CBT or pharmacotherapy seem to be the most effective for panic disorder

A

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

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28
Q

which was more effective for panic disorder, CBT that included interoceptive exposure or relaxation therapy

A

CBT that included interoceptive exposure

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29
Q

name two factors that improved the effectiveness of psychological treatments for panic disorder

A

inclusion of homework

follow up program

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30
Q

how do minimal intervention formats I.e self help books, internet based CBT, compare in efficacy compared to other psychological treatments for panic disorder

A

more effective than wait list or relaxation controls

as effective as face to face CBT

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31
Q

how long are CBT protocols for panic disorder

A

usually 12-14 weeks but shorter 6-7 session programs have been shown to be as effective

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32
Q

list predictors of decreased response to CBT for panic disorder

A

severity of panic disorder

strength of blood/injury fears

earlier age of onset of initial symptoms

comorbid social anxieties

degree of agoraphobic avoidance

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33
Q

name two key process variables in CBT therapy for panic disorder

A

changes in beliefs and changes in avoidance behaviours

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34
Q

does EMDR appear to be effective for panic disorder

A

EMDR does not seem to be more effective as the same strategy without the eye movement component

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35
Q

in panic disorder, is combo CBT + med therapy superior?

A

seems to be better than either CBT or meds alone during acute treatment phase and while meds were continued

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36
Q

what should be considered first line treatment for panic disorder

A

CBT alone or CBT + meds

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37
Q

is there benefit to CBT + benzos for treatment of panic disorder

A

does not seem to be (compared with psychotherapy or meds alone)

*followup suggests combo might be WORSE than behaviour therapy alone

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38
Q

what has been shown to be helpful in facilitating benzo discontinuation in those with panic disorder

A

CBT

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39
Q

how long were benefits of CBT maintained for those with panic disorder

A

up to 3 years

(one study shows 62% remained in remission after 10 years(

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40
Q

list first line meds for treatment of panic disorder

A

Call Every Familiar Fun Person Said Veronica

*SSRIs/SNRIs

Citalopram

Escitalopram

Fluoxetine

Fluvoxamine

Paroxetine

Sertraline

Venlafaxine XR

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41
Q

list second line meds for treatment of panic disorder

A

All Cats Can Dance In Lazy Morning Rounds

*lots of benzos in this list

Alprazolam

Clomipramine

Clonazepam

Diazepam

Imipramine

Lorazepam

Mirtazapine

Reboxetine

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42
Q

list third line meds for treatment of panic disorder

A

*the random drugs, including mood stabilizers, anticonvulsants and antipsychotics

Buproprion SR

divlaproex

duloxetine

gabapentin

levetiracetam

milnacipran

moclobemide

olanzapine

phenelzine

quetiapine

risperidone

tranylcypromine

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43
Q

what medications are NOT recommended in panic disorder

A

buspirone

propanolol

tiagabine

trazodone

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44
Q

are there any first line adjunctive therapies for panic disorder

A

no

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45
Q

list two second line adjunctive therapies for panic disorder

A

alprazolam, clonazepam

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46
Q

list five third line adjunctive therapies for panic disorder

A

aripiprazole

divalproex

olanzapine

pindolol

risperidone

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47
Q

what benefits have been shown from SSRIs in the treatment of panic disorder

A

panic symptoms

agoraphobic avoidance

depressive symptomatology

general anxiety

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48
Q

how does efficacy compare between TCAs and SSRIs in the treatment of panic disorder

A

similar efficacy but TCAs tend to be not as well tolerated and have higher discontinuation rates

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49
Q

in which patients with panic disorder might you consider moclobemide and why

A

treatment resistant patients who are severely ill as while results for efficacy mixed for panic disorder, shows significant efficacy in severely ill patients

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50
Q

how effective is risperidone at treating panic disorder

A

RCT showing risperidone having similar efficacy as paroxetine to treat panic disorder

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51
Q

list the 3 AAPs with evidence (open label) for treating panic disorder

A

olanzapine

risperidone

quetiapine

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52
Q

why might you consider using alprazolam or clonazepam short term at initiation of SSRI therapy for panic disorder

A

can lead to a more rapid response

use for less than 8 weeks including taper of the benzo

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53
Q

what is the RCT data for pindolol in the treatment of panic disorder

A

adjunctive

when combined with fluoxetine in patients with treatment resistant panic disorder, associated with significant improvement in symptoms compared with fluoxetine + placebo

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54
Q

is there evidence for neurostimulation treatment for panic disorder

A

open label/level 3/4 evidence

  1. REAC (radioeelctric asymmetric conveyor)–> efficacy for panic sx and agoraphobia
  2. rTMS in patients with comorbid MDD but results mixed
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55
Q

what are some alternative therapies for panic disorder

A
  1. capnometry assisted respiratory training –> was as effective as cognitive training in reducing symptom severity and panic related cognitions and improving perceived control
    (results mixed)
  2. 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
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56
Q

what approached to treatment for panic disorder are supported by the evidence

A

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

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57
Q

who is considered to have treatment refractory panic disorder

A

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

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58
Q

what is the treatment of choice for specific phobias

A

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)

59
Q

list factors that have shown to make exposure based therapy for specific phobias more effective

A

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

60
Q

for specific phobias treatment, is flooding or gradual exposure more effective

A

no evidence either way but progressive exposures are more tolerable to patients generally

61
Q

are psychological treatment outcomes for specific phobias moderated by the type of specific phobia?

A

no–> but studies have suggested that certain types may respond more favorably to specific types of treatment

62
Q

what should be combined with exposure therapy for those with blood/injection/needle phobia

A

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)

63
Q

what type of psychosocial intervention is recommended for fear of flying

A

group CBT

computer generated VR exposure

(bibliotherapy less effective)

64
Q

list some specific phobias for which virtual reality exposures have evidence of efficacy

A

fear of flying

fear of heights

claustrophobia

arachnophobia

65
Q

what compound has been speculated to improve extinction of fear in patients with specific phobias undergoing behavioural exposure therapy

A

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

66
Q

what is d-cycloserine

A

a partial agonist at the NMDA receptor

speculated to improve extinction of fear in patient with specific phobias undergoing behavioural exposure therapy

67
Q

what is yohimbine

A

yohimbine hydrochloride = noradrenaline agonist

?facilitate fear extinction as enhanced emotional memory may be stimulated through elevated noradrenaline levels

not good data from RCTs

68
Q

is there a large role for pharmacotherapy in the treatment of specific phobias

A

no–> “minimal role” (largely due to lack of research)

mainstay is CBT + exposures

69
Q

name 4 antidepressants that have some (if small) evidence for benefit in treating specific phobias

A

paroxetine

escitalopram

fluoxetine (flying phobias)

fluvoxamine (storm phobia)

70
Q

is there evidence for adjunctive benzos combined with exposure therapy for specific phobias

A

no

71
Q

is pharmacotherapy generally a recommendation for treatment for specific phobias

A

no not really–> exposure based techniques are highly effective

72
Q

what is the estimated lifetime prevalence of social anxiety disorder

A

8-12% internationally

(higher rates in developed vs developing countries)

73
Q

what is the mean age of onset of social anxiety disorder

A

12 years old

74
Q

what is the typical course of social anxiety disorder

A

chronic and unremitting

75
Q

how does social anxiety disorder affect disability

A

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

76
Q

list psychiatric conditions commoly comorbid with social anxiety disorder

A

MDD and other anxiety disorders = highest rates

avoidant PD

body dysmorphic disorder

SUD

ADHD

schizophrenia

77
Q

what is considered the gold standard nonpharmacological treatment for social anxiety disorder

A

CBT

78
Q

what are the main cognitive techniques involved in CBT for social anxiety disorder

A

restructuring and challenging maladaptive thoughts

behavioural component –> typically in form of exposure therapy

79
Q

how does efficacy compare between CBT and pharmacotherapy for social anxiety disorder

A

similar

?changes persist long with CBT

80
Q

is videotaped feedback helpful as enhancement for exposure based treatment for social anxiety disorder

A

no

81
Q

what type of CBT was found to be as effective as standard CBT but also improved relationship satisfaction and social approach behaviours

A

CBT focused in interpersonal behaviour

82
Q

is there evidence to support IPT in social anxiety disorder

A

conflicting evidence

likely more effective than wait list control but less effective than CBT

83
Q

which has more long term benefit for treatment of social anxiety disorder, psychotherapy or pharmacotherapy

A

seems to be psychotherapy

84
Q

is there good evidence for pharmacological interventions for social anxiety disorder

A

yes-> SSRIs, SNRIs, anticonvulsants, and benzos

85
Q

list first line agents for treatment of social anxiety disorder + mnemonic

A

Every Fungus Packs Pretty Sweet Value

Escitalopram

Fluvoxamine and fluvoxamine CR

Paroxetine and paroxetine CR

Pregabalin

Sertraline

Venlafaxine XR
l

86
Q

list second line agents for social anxiety disorder + mnemonic

A

All Bros Can Carry Giant Pigs

Alprazolam

Bromazepam

Citalopram

Clonazepam

Gabapentin

Phenelzine

87
Q

list third line agents for social anxiety disorder

A

atomoxetine

buproprion SR

clomipramine

divalproex

duoxetine

fluoxetine

mirtazapine

moclobemide

olanzapine

selegiline

tiagabine

topiramate

88
Q

list two medications that are NOT recommended as adjunctive therapy for social anxiety disorder

A

clonazepam

pindolol

89
Q

why is fluoxetine third line for social anxiety disorder

A

there are NEGATIVE trials of fluoxetine in social anxiety disorder suggesting less effective than other SSRIs

90
Q

are there any first line adjunctive therapies for social anxiety disorder

A

no–> only third line

91
Q

list the (third line) adjunctive therapies for social anxiety disorder

A

abilify

buspirone

paroxetine

risperidone

92
Q

list medications NOT recommended in the treatment of social anxiety disorder

A

atenolol

buspirone

imipramine

keppra

propanolol

quetiapine

*beta blockers can be useful for performance but not generally

93
Q

what doses of pregabalin have been shown to be effective for social anxiety disorder

A

higher doses (i.e 600mg/day) rather than lower doses (150mg/day) is effective

*unclear how efficacy of pregabalin compares to SSRIs

94
Q

how do benzos compare to SSRIs in efficacy for treating social anxiety disorder

A

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

95
Q

why is phenelzine restricted to second line recommendation social anxiety disorder despite level 1 evidence for efficacy

A

due to concerns around dietary restrictions, drug interactions and potential for hypertensive crisis

96
Q

is keppra recommended in social anxiety disorder

A

no

97
Q

is quetiapine recommended for treatment of social anxiety disorder

A

no

98
Q

is buspirone recommended for treatment of social anxiety disorder

A

no

99
Q

is risperidone recommended for treatment of social anxiety disorder

A

third line

100
Q

is fluoxetine recommended for treatment of social anxiety disorder

A

third line

101
Q

is fluvoxamine recommended for treatment of. social anxiety disorder

A

first line

102
Q

is citalopram recommended for treatment of social anxiety disorder

A

second line

103
Q

is escitalopram recommended for treatment of social anxiety disorder

A

first line

104
Q

is paroxetine recommended for treatment of social anxiety disorder

A

first line

105
Q

is sertraline recommended for social anxiety disorder

A

first line

106
Q

is gabapentin recommended for social anxiety disorder

A

second line

107
Q

is phenelzine recommended for social anxiety disorder

A

second line

108
Q

is there generally long term therapy for specific phobias

A

no not generally

109
Q

is there indication for long term medication treatment in social anxiety disorder

A

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)

110
Q

name a biological/neurostim therapy that has shown evidence for efficacy in social anxiety disorder

A

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

111
Q

is st johns wort recommended for treatment of social anxiety disorder

A

no

failed to demonstrate superiority over placebo

112
Q

has adding pharmacotherapy to CBT been shown to increase the benefits of CBT in the treatment of social anxiety disorder

A

no

113
Q

what is the estimated lifetime prevalence of GAD

A

about 6%

114
Q

in what population is GAD more frequenct

A

caucasians

115
Q

what is the age of onset of GAD

A

may be bimodal

median age is 31 years and mean age is 32.7 years

116
Q

what is the usual age of onset for GAD in kids and teens

A

10-14 years

117
Q

what % of those with GAD report painful physical symptoms

A

60-94%

main reason for presentation in primary care in 72% of cases

118
Q

what medical syndromes have elevated risk in those with GAD

A

pain syndromes

HTN

CV and gastro conditions

119
Q

list problems that have been specifically identified among those with GAD that have become part of evidence based CBT protocols for GAD

A

intolerance of uncertainty

poor problem solving confidence

positive and negative metacognitive beliefs about the function or utility of worry

120
Q

list psychotherapeutic interventions that have evidence in GAD treatment

A

Acceptance based behaviour therapy

meta cognitive therapy

CBT targeting intolerance of uncertainty

adjunctive MBCT

*meta analyses clearly support CBT

121
Q

is psychodynamic therapy helpful for GAD

A

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

122
Q

what are the benefits of adding pre treatment motivational interviewing as an adjunct to CBT for GAD

A

helps reduce resistance to therapy

improves homework compliance

improves worry outcomes

123
Q

is psychotherapy, pharmacotherapy or combo best for treatment of GAD

A

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)

124
Q

is there evidence to support the routine combo of CBT + pharmacotherapy in GAD

A

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)

125
Q

are the benefits of CBT maintained for those with GAD

A

yes–> seem to be maintained at 1-3 years

126
Q

first line pharmacotherapy for GAD

A

Anxious People Pray So Voraciously Every Day

Agomelatine

Paroxetine + paroxetine CR

Pregabalin

Sertraline

Venlafaxine XR

Escitalopram

Duloxetine

127
Q

second line pharmacotherapy for GAD

A

Anyone Buying Biscuits Begins Quietly Hiding Desserts In Locked Vehicle

Alprazolam

Bromazepam

Buproprion XL

Buspirone

Quetiapine

Hydroxyzine

Diazepam

Imipramine

Lorazepam

Vortioxetine

128
Q

third line pharmacotherapy for GAD

A

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

129
Q

name a second line adjunctive agent for treatment of GAD

A

pregabalin

130
Q

name 4 third line adjunctive agents for treatment of GAD

A

aripiprazole

olanzapine

quetiapine/quetiapine XR

risperidone

131
Q

name an agent that is NOT recommended as an adjunctive agent for GAD

A

ziprasidone

132
Q

name 3 medications that are NOT recommended for treatment of GAD

A

beta blockers (i.e propanolol)

pexacerfont

tiagabine

133
Q

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

A

the benzodiazepines, except where there is a risk of substance use

(buproprion would likely be reserved for later)

134
Q

in which patients would you consider using quetiapine XR for treatment of GAD

A

patients who cannot be given antidepressants or benzos

*does have good efficacy though, its just the concerns about metabolics due to being an AAP

135
Q

how does efficacy compare between pregabalin and benzos in treatment of GAD

A

similar (pregabalin as effective as benzos)

(and was more effective than venlafaxine in one trial and equally efficacious in another)

136
Q

buproprion XL wa shown to be as effective as which SSRI for treatment of GAD

A

escitalopram (a first line option)

137
Q

what is the evidence for use of vortioxetine in GAD

A

second line recommendation

level 1, conflicting evidence

one trial showed benefit one did not but ?due to difference in recruitment in the studies?

138
Q

how does quetiapine compare in terms of efficacy to antidepressants for GAD

A

equally efficacious but lead to more weight gain and sedation and had higher dropout rates

139
Q

what evidence is there for adjunctive risperidone in GAD

A

limited–> only showed benefit over placebo in those with moderate to severe residual symptoms

140
Q

what neurostimulation therapy may be beneficial for treatment of GAD

A

rTMS as monotherapy or adjunctive to SSRI

141
Q

list 4 herbal preparations that may have efficacy in GAD

A

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

142
Q

name a lifestyle intervention that has evidence for improving GAD symptoms

A

weightlifting or aerobic exercise

*significant symptomatic improvements compared to wait list condition

143
Q

is there evidence for bright light therapy for GAD

A

no (when compared with placebo) and thus is not recommended

144
Q

is CBT first line for GAD

A

yes, is an effective FIRST LINE option for GAD and is AS EFFECTIVE as pharmacotherapy

5. Anxiety Disorders (4 decks)

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