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DSM-V > Guidelines > Flashcards

Guidelines Flashcards

1
Q

Order of age of development of anxiety disorders?

A
  1. separation anxiety (as early as preschool age)
  2. selective mutism (onset before 5)
  3. specifc phobias (5-12, majority before 10; animal BII earlier than situational)
  4. SAD (13ish)
  5. OCD (19ish)
  6. panic disorder (early 20s)
  7. agoraphobia (late adolescence, early adulthood)
  8. PTSD (any age, often mid to late 20s)
  9. GAD (bimodal onset, late teens/adolescents, 30-40s)
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2
Q

What percentage of people with an anxiety disorder have a comorbid psychiatric condition?

A

60-80%

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3
Q

What is the most common type of psychiatric comorbidity with an anxiety disorder?

A

Other anxiety disorders:
>50% have 2+ anxiety disorders
30% have 3+ anxiety disorders

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4
Q

Are depression or anxiety disorders more comorbid with anxiety?

A

Anxiety disorders (>50 have 2+ anxiety disorders).

MDD = 20-36% comorbid

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5
Q

What percentage of people with an anxiety disorder have a bipolar disorder? and vice versa?

A

14% of ppl with anxiety have bipolar I/II

52% of people with bipolar have a lifetime anxiety diagnosis

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6
Q

What percentage of ppl with ADHD have an anxiety disorder? And what’s the most common one?

A

47%

Social anxiety disorder (29%)

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7
Q

What percentage of ppl with an anxiety disorder have a comorbid medical or pain disorder?

A

> 60% (so really, the most common comorbidity).

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8
Q

First line medications for panic disorder?

A

All 6 SSRIs (CEFFPS)

And Venlafaxine

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9
Q

Second line meds for panic disorder?

A

Mirtazapine

clompiramine, imipramine

benzos (alprazolam, clonazepam, diazepam, lorazepam)

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10
Q

Third line meds for panic disorder?

A

bupropion
duloxetine

moclobemide

divalproex
gabapentin
Keppra
olanzapine
quetiapine
risperidone

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11
Q

Adjunctive therapy for Panic disorder?

A

No fist line.

Second line = alprazolam, clonazepam

Third line = aripiprazole, olanzapine, risperidone, divalproex

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12
Q

What meds are not recommended for panic disorder?

A

buspirone
propranolol
trazodone
tiagabine

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13
Q

What is first line for psychotherapy in panic disorder?

A

obv psychoed (for all anxiety disorders), and being encouraged to face fears.

Specifically – CBT with interoceptive exposure

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14
Q

In the acute phase of panic disorder, what’s better - meds, therapy, or both?

A

Combination is better than CBT alone
Combination is better than meds alone

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15
Q

In the maintenance phase of panic disorder, what’s better - meds, therapy, or both?

A

Combination is better than meds alone

combination is EQUAL to psychotherapy alone

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16
Q

Should you do meds, therapy, or both for specific phobias?

A

Therapy, exposure based is best.

Meds have minimal role.

VR works for flying, spiders, heights, claustrophobia

Computer based self help programs works for flying, spiders, small animals

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17
Q

First line med options for SAD?

A

4 SSRIs (EFvPS)
venlafaxine

pregabalin

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18
Q

Second line med options for SAD?

A

citalopram

gabapentin

alprazolam, clonazepam

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19
Q

Third line med options for SAD?

A

fluoxetine
bupropion
duloxetine
mirtazapine

atomoxetine

olanzapine
divalproex
topiramate

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20
Q

Adjunctive therapy?

A

Only third line: abilify, risperidone, buspirone, paroxetine

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21
Q

is quetiapine recommended in SAD?

A

No.

Nor is buspirone or propranolol (except in performance only)

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22
Q

Are meds or therapy or combo better in SAD?

A

Acute: Meds = therapy. Combo (seems to) = therapy alone.

BUT after treatment discontinuation, psychotherapy is more enduring than meds.

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23
Q

What meds are first line for GAD?

A

EPS (escitalopram, paroxetine, sertraline)
duloxetine
venlafaxine

agomelatine
pregabalin

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24
Q

What meds are second line for GAD?

A

vortioxetine
bupropion

buspirone
imipramine

benzos (alprazolam, clonazepam, lorazepam)
quetiapine

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25
Q

What meds are second line for GAD?

A

citalopram
fluoxetine
mirtazapine
trazodone

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26
Q

Adjunctive meds for GAD?

A

second line is pregabalin

third line is aripiprazole, olanzapine, quetiapine, risperidone

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27
Q

Whats better for GAD - meds, therapy, both?

A

CBT = meds
combo > CBT alone at post treatment, but not at 6 month follow up

no recommendations to routinely combine

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28
Q

what psychotherapy is best for GAD?

A

CBT (group = individual, but earlier improvement with individual)

maybe some evidence for relaxation therapy, balneotherapy, psychodyamic, ACT, adjunctive MBCT

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29
Q

Any biological therapies for GAD?

A

rTMS is effective as monotherapy or as adjunct to SSRIs

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30
Q

First line med treatments for OCD?

A

5 SSRIs - EFFPS

31
Q

Second line med treatments for OCD?

A

citalopram
venlafaxine
mirtazapine

clompiramine

32
Q

Adjunctive therapy for OCD?

A

first line: abilify, risperidone

second line: memantine, quetiapine, topiramate

third line: ketamine, mirtaz, NAC, olanzapine, pregabaline, haldol, ondansetron

33
Q

What’s better for OCD - meds, therapy, or both?

A

Combo > meds alone
Combo is NOT SUPERIOR to CBT alone

CBT = or > meds

adding CBT to meds enhances response, reduces relapse rates

34
Q

What’s the best psychotherapy for OCD?

A

CBT, generally ERP

but Danger Ideation Reduction Therapy (DIRT) is maybe even more efficacious than ERP (no direct exposure, only addresses fear of contamination).

35
Q

First line meds for PTSD?

A

3 SSRIs –> FtPS
venlafaxine

36
Q

Second line meds for PTSD?

A

fluvoxamine
mirtazapine

phenelzine

37
Q

Third line for PTSD?

A

bupropion
duloxetine
escitalopram

many others - abilify, quetiapine, risperidone, lamotrigine, buspirone, amitriptyline, memantine.. etc.

38
Q

Adjunctive therapy for PTSD?

A

second line: risperidone, olanzapine, zopiclone

third line: quetiapine, abilify, gabapentin, pregabalin, clonidine, keppra

39
Q

what med is interestingly NOT recommended in PTSD

A

citalopram

also olanzapine and divalproex

40
Q

Are meds or therapy better for PTSD?

A

mixed findings.

both effective. maybe psychotherapy is less effective than meds.

41
Q

what psychotherpay is recommended in PTSD?

A

CBT
Types:
TF-CBT, EMDR (fastest recovery), are best.

Also stress management, prolonged exposure, cognitive processing therapy, CRE, have evidence.

interestingly supportive treatment not effective.

42
Q

meds recommended in pregnancy for anxiety disorders?

A

any ssri fine except not paroxetine (maybe cardiac defects).

side effect is poor neonatal adaptation syndrome, self limiting, supportive care.

sometimes persistent pulmonary hypertension (more serious)

43
Q

benzos in pregnancy?

A

maybe increased risk of oral cleft defects, neonatal withdrawal/toxicity.

44
Q

SSRIs in breastfeeding?

A

sertraline, paroxetine lowest amounts

45
Q

antipsychotics in pregnancy?

A

probably fine, not risk of malformations, low in breast milk

risk of abnormal muscle movement, maybe withdrawal symptoms.

can increase metabolic syndrome, weight gain and thus complications.

46
Q

Medication differences for children in anxiety disorders?

A

fluoxetine AND fluvoxamine are recommended in ALL – separation, SAD, GAD, OCD (except panic and PTSD)

47
Q

Psychotherapy interventions for acute mania

A

nil

48
Q

psychotherapy interventions for acute depression – first, second third line

A

No first line

Second line – CBT, Family focused therapy

third line – IPSRT (interpersonal and social rhythm therapy)

49
Q

Psychotherapy for maintenance of bipolar disorder - first, second third line

A

first line = psychoeducation

second line = CBT and family focused therapy

third line = IPSRT - interpersonal and social rhythm therapy and peer support

50
Q

what medications are first line for Bipolar 1 acute mania (monotherapies)?

A

(in order you should try them):

lithium
quetiapine
divalproex
asenapine
aripiprazole
palipderidone >6mg
risperidone
cariprazine

51
Q

What medications are first line for Bipolar 1 acute mania (combination therapies)?

A

Quetiapine + Li/DVP
Aripiprazole + Li/DVP
Risperidone + Li/DVP
Asenapine + Li/DVP

Combo is preferred since only 50% respond with mono, 80% respond with combo, but of course more side effects

52
Q

What medications are second line for bipolar 1 acute mania?

A

Olanzapine
Carbamazapine
Olanzapine + Li/DVP
Lithium + DVP
Ziprasidone
Haloperidol
ECT (80% will respond)

53
Q

Reasons to do lithium? Reasons not to do lithium?

A

classic euphoric grandiose mania, family history of bipolar

Not choose in: mixed features, comorbid substance use

54
Q

Reasons for choosing divalproex

A

maybe better in dysphoric mania, predominant irritable or dysphoric mood, comorbid substance abuse, history of head trauma, mixed features

55
Q

if there’s psychosis and mania, what meds should you choose?

A

Probably antipsychotic + Li/DVP

56
Q

First line treatments for Bipolar 1 acute depression?

A

Quetiapine
Lurasidone + Li/DVP
Lithium
Lamotrigine
Lurasidone
Lamotrigine (adj)

*don’t choose lamotrigine if need rapid response

57
Q

second line treatments for bipolar 1 acute depression?

A

Divalproex
SSRIs/bupropion (adj)
ECT
Cariprazine
Olanzapine-fluoxetine

58
Q

what to not choose for bipolar 1 acute depression?

A

abilify

antidepressant monotherapy

59
Q

best meds for anxious distress in acute depression bipolar 1?

A

olanzapine-fluoxetine, lurasidone, asenapine

60
Q

if psychotic in acute depression bipolar 1, how to treat?

A

ECT and/or antipsychotics

61
Q

how to treat rapid cycling in bipolar 1?

A

treat hypothyroidism
do not use antidepressants
treat substance abuse (also associated with rapid cycling)

62
Q

How to treat bipolar 1 in the maintenance phase?

A

Generally continue meds that worked in acute, except for adjunctive antidepressants are not recommended due to manic switch risk

63
Q

What meds are first line for Bipolar 1 maintenance?

A

Lithium
Quetiapine
Divalproex
Lamotrigine
Asenapine
Quetiapine + LI/DVP
Aripiprazole + LI/DVP
Aripiprazole

64
Q

What meds are second line for Bipolar I maintenance?

A

Olanzapine
Risperidone LAI
Risperidone LAI (adj)
Carbamazepine
Paliperidone >6mg
Lurasidone + Li/DVP
Ziprazidone + Li/DVP

65
Q

What is first line for Bipolar II acute depression?

A

Only quetiapine

66
Q

What is second line for Bipolar II acute depression?

A

Lithium
Lamotrigine
Bupropion (adj)
ECT
Sertraline (if pure, non-mixed depression)
venlafaxine (if pure, non-mixed depression)

67
Q

What is first line for bipolar II maintenance?

A

quetiapine
lithium
lamotrigine

68
Q

what is first line for bipolar II acute hypomania?

A

not studied.
basically meds that can worsen or prolong symptoms, including antidepressants and stimulants

start something that works in mania – generally what works in mania works in hypomania so if the hypomania is frequent, severe, impairing, consider a mood stabilizer like lithium, DVP or atypical antipsychotics

69
Q

What does OCP do to lamotrigine?

A

causes lower levels

70
Q

first line for children/adolescents with acute mania medications?

A

use lithium, risperidone, abilify, asenapine, and quetiapine

71
Q

children/adolescents with acute bipolar depression - first line treatment?

A

lurasidone first line, and lithium/lamotrigine as second line

72
Q

Older adults - first line in acute mania?

A

LI, DVP as first line, then quetiapine is second-line

73
Q

special considerations for substance use (alcohol, stimulants, opioids) and bipolar, what to do with medications?

A

In alcohol and cannabis comorbid, Use Li or DVP, quetiapine not recommended was no efficacy.

Stimulants: can use Li, DVP, quetiapine, bupropion, lamotrigine.

Opioid: no recommendations

74
Q

how to treat comorbid anxiety and bipolar?

A

use pregabalin or gabapentin as effective and not associated with mood destabilization

SSRIs better than SNRIs – less likely for manic switch

Do CBT, benzos sparingly

DSM-V (6 decks)

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