Panic Disorder, OCD, and PTSD Flashcards
Panic Disorder
Recurrent, unexpected panic attacks
> 1 month of persistent concern or worry about additional
panic attacks and consequences +/- notable maladaptive
behavior change related to attacks
Relapse-remitting
Panic attack in isolation does not constitute a disorder
Very common to have a comorbid mental health condition
(approx. 90%) or other medical disorder
One of the most common concurrent mental health conditions that we see with panic disorders, agoraphobia. Agoraphobia is this fear of going outside.
There is also a very high proportion of people with panic disorder who will experience nocturnal panic, which is the phenomenon of waking up from sleep in a state of panic. Anywhere 40-70% of patients will experience that.
Panic Disorder - DSM
often people will actually confuse a panic attack with very serious medical presentation such as a heart attack or an asthma exacerbation.
An abrupt surge of intense fear or discomfort in which four (or more)
symptoms develop and reach a peak within minutes:
Palpitations, pounding heart (increased HR)
Sweating
Trembling or shaking
Sensation of shortness of breath or smothering
Feelings of choking
Chest pain or discomfort
Nausea or abdominal distress
Dizziness, feeling unsteady, light-headed, or faint
Chills or heat sensations
Paresthesias (numbness or tingling)
Derealization or depersonalization
Fear of losing control or “going crazy”
Fear of dying
Panic Disorder goal
Reduce the frequency and severity of attacks
Reduce anticipatory anxiety
Reduce avoidance and impaired function
First line tx
CBT alone or CBT with pharmacotherapy (antidepressants)
CBT + AD combination has superior remission/response rates at 6-24 month follow up
CBT alone may be insufficient in more severe cases
Best psychological treatment
Minimal intervention formats are as effective as face-to-face CBT
Minimal intervention formats = self help books, phone/video conferencing, internet based
Meta-analyses suggest that first-line treatment is either cognitive behavioral therapy alone or CBT with pharmacotherapy. And for pharmacotherapy, what we typically see as antidepressants
minimal intervention formats, which are things like self-help books, internet-based CBT, phone or video based CBT have been shown to be as effective as face-to-face CBT,
combination of CBT and pharmacotherapy is superior to either of those options alone
Panic Disorder - Treatment
Individuals with PD are very sensitive to physical
experiences
Start with LOW dosing
Often do better with lower dosing in general
Monitor that avoidance has stopped (not just
panic symptoms)
If anxiety is severe, use benzodiazepines at any
time
Adding a BZD as an adjunct in the first 8 weeks
can lead to a more rapid response
we start with low doses as individuals are typically quite sensitive to physical experiences and they generally don’t require high doses for treatment. And so if an antidepressant is being started for panic disorder, we actually will often consider including a benzodiazepine and those first two weeks of treatment.
And this is used to bridge some of the data, shows that it might actually lead to a more rapid response, even though we know that antidepressants typically take anywhere 6-8 weeks for efficacy. That bridging period with a benzodiazepine can be helpful. We should make sure that when we’re initiating tapers, we’re doing this very gradually, at least over an eight-week period.
second-line treatment, there is some suggestion that TCAs could have some effect. They do have comparable efficacy, but the backs the downfall of being that they have worse tolerance. MOA studied in limited capacity
Obsessive-Compulsive
Disorder (OCD)
Least common anxiety disorder
Mean age of onset is approximately 20 years of age
- But generally we see very few new cases detected after the age of 30.
Risk factors:
Social isolation
History of physical abuse
Negative emotionality (negative emotions, poor selfconcept/esteem)
Up to 1 in 4 patients with OCD have attempted suicide
Severely debilitating
Reduced QOL for patients and family/caregive
O BSESSI O N S\
compulsions
Recurrent, intrusive thoughts,
images, or urges caused marked
anxiety and stress
Examples: contamination,
symmetry/exactness, safety,
sexual impulse, aggressive
impulses, somatic, religious
compulsionsL:
Repetitive behaviors or mental
acts performed in an attempt to
reduce anxiety from obsessions
(usually excessive or unrealistic)
Examples: checking, washing,
repeating, ordering, counting,
hoarding, touching
OCD - DSM 5
Obsessions that are intrusive and unwanted causing marked anxiety or stress
Individual attempts to ignore or suppress such thoughts, urges, or images, or to
neutralize them with other thoughts or actions
Compulsions aimed at preventing or reducing anxiety related to obsessions or
preventing some dreaded situation or event
Often not connected in a realistic way with what they are designed to neutralize, or
are clearly excessive
AND/OR
Often time consuming (>1h/day) and causes clinically significant distress or functional
impairment
Degree of insight may vary
Yale-Brown Obsessive Compulsive
Scale (Y-BOCS)
10 item clinician administered scale
Used to rate symptom severity; not a diagnosis
Initially completed by the patient and then reviewed
Can help to recognize thoughts and behaviors related to
their illness; can help elucidate which symptoms should
be targeted for treatment
Five rating dimensions for obsessions and compulsions;
each scored on a 4 point scale
this is a scale that’s often initially completed by the patient and then reviewed by the clinician. And it can help to recognize both the thoughts and behaviors that are related to the condition itself. And so this can help people again, have greater insight about the compulsions that they’re having, the obsessions that they’re having. It can also help them identify which symptoms should perhaps be targeted for treatment
decrease of greater than or equal to 35% in Y-BOCS score can have really clinically meaningful response and translate into global improvement for patients.
OCD - Treatment
Difficult to treat
CBT equivalent or superior to pharmacotherapy
Combination superior to pharmacotherapy alone but NOT to CBT alone
Responds to 5-HT but minimally to NE
1st line:
SSRIs: Meta-analyses, suggest that response rates with SSRIs are generally twice that of placebo. So what we’re seeing is with SSRIs, patients are experiencing maybe 40 to 60% response rates versus like less than 20% with placebo
2nd line:
Clomipramine (similar efficacy to SSRIs but reduced tolerability), could be considered after a trial of two first-line agents. And if those two first-line agents have failed, we can consider either switching to clomipramine or adding it as an adjunct therapy.
Venlafaxine
Mirtazapine
Third line: IV clomipramine, duloxetine, MAOIs, tramadol
NOT recommended: clonazepam, clonidine, desipramine
treatment resistant patients may benefit from the third line treatment,
4-14 times greater than those obtained with oral dosing. So what that means is that we’re getting much higher brain, brain levels of the medication
OCD - Adjuncts
First line adjuncts: risperidone (0.25-4mg/day), aripiprazole
Second line adjuncts: quetiapine (25-100mg/day), topiramate
Most evidence for antipsychotics in OCD is for use as adjunctive treatment.
2011 systematic review (REF) showed evidence of benefit with risperidone versus
placebo.
Adjunct response rates are double that of placebo but relatively still low (31.8% vs
13.6%)
it’s really important that we make efforts to preserve any benefits of treatment so that we may consider adjuncts earlier rather than later, which is something that’s a bit less common and other conditions.
OCD - Dosing
unique dosing
Rapid titration (q1-2 weeks) to highest tolerated dose in upper half of dosing range
often very high doses of antidepressants required
Clomipramine 100-300mg/day
Fluvoxamine 50-300mg/day
Fluoxetine 20-80mg/day
Paroxetine 20-60mg/day
Sertraline 50-225mg/day
Venlafaxine 75-300mg/day
Phenelzine 30-90mg/da
So clinicians will typically titrate doses more aggressively and more rapidly. And so we’ll see titrations maybe every one or two weeks to the highest tolerated dose. And that’s usually in the upper half of the dosing range that’s available in the literature. And so patients will often end up on very high doses of SSRIs in the context of treating OCD.
ocd how long to treat for?
Benefit onset may be >6 weeks (10-12 weeks)
Treat for a minimum of 6 months after acute treatment
- some dguidelines recommend 1-2yrs
Very gradual discontinuation of treatment recommended
- watch closely for signs of relapse
Many will require lifelong treatment
Post-Traumatic Stress Disorder (PTSD
L if e t ime pr e v a l enc e in C anada = 9. 2 %
M os t common forms of t r auma r e sul t ing in
PTSD inc lude : une xpe c t ed de a th of
someone c los e , s e xua l a s s aul t , s e r ious
i l lne s s /injur y to someone c los e , ha v ing a
chi ld wi th s e r ious i l lne s s , or int ima t e
pa r tne r or c a r e g i v e r v iol enc e
Int rus i v e r e - e xpe r i enc e of a t r auma t i c
e v ent , a voidanc e of s t imul i , hype r a rous a l ,
ne g a t i v e cogni t ion/mood
C l ini c a l l y s i gnifi c ant di s t r e s s or
impa i r ed func t ion
H i gh sui c ide r a t e s ( 2 - 3 x r i s k )
4 0 % comba t PTSD e xpe r i enc e ps y chot i c
s ymptoms
for patients who are experiencing PTSD, it’s more likely to occur as a result of an interpersonal event rather than an accident or natural disaster.
PTSD is that the onset of symptoms can be very delayed in in correlation to when the event happened. So PTSD can actually be diagnosed or have onset symptoms years after the exposure.
PTSD - DSM 5
EXPOS U RE TO A C T U AL OR THREATENED DEATH, SERIOU S INJ U RY, OR SEX U AL VIOLAT ION VIA ≥ 1 WAY:
- Directly experienced or witnessed the traumatic event
- Learned that trauma occurred to close family member or friend (actual or threatened death must have been violent or accidental)
- Experienced repeated exposure to aversive details of trauma
AT L EAST ONE INTR U SION SY M PTOM :
- Recurrent, involuntary, and intrusive distressing memories
- Distressing dreams
- Dissociative reactions (e.g., flashbacks)
- Psychological or physiological distress at reminders of trauma
PERSISTENT AVOIDANC E OF ≥ 1 ST IM U L I ASSOC IATED WI TH TH E TRA U M A
- Avoidance of distressing memories or feelings and external reminders (e.g., people, places) of the traum
requires an exposure to trauma that is characterized by intrusive and distressing memories or reactions, and then a substantial either psychological or physiological distress response related to those events.
to meet the diagnostic criteria, there must be a persistent avoidance of one or more of the stimuli associated with the trauma. And these disturbances must have been present for at least one month.
