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Collège royal > Troubles anxieux > Flashcards

Troubles anxieux Flashcards

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1
Q

what is the lifetime prevalence of anxiety disorders

A

31% estimated (higher than mood or SUDs)

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2
Q

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

A

estimated 40%

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3
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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4
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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5
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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6
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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7
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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8
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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9
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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10
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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11
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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12
Q

which SEs of SSRIs, SNRIs may persist throughout treatment

A

weight gain and sexual dysfunction

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13
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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14
Q

can benzos cause cognitive impairment after discontinuation

A

yes–> has been reported persisting beyond cessation of therapy

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15
Q

side effects of buspirone

A

dizziness

drowsiness

nausea

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16
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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17
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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18
Q

what is the lifestime estimated prevalence of panic attacks

A

28.3%

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19
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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20
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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21
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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22
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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23
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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24
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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25
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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26
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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27
Q

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

A

CBT

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28
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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29
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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30
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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31
Q

what medications are NOT recommended in panic disorder

A

buspirone

propanolol

tiagabine

trazodone

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32
Q

are there any first line adjunctive therapies for panic disorder

A

no

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33
Q

list two second line adjunctive therapies for panic disorder

A

alprazolam, clonazepam

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34
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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35
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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36
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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37
Q

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

A

olanzapine

risperidone

quetiapine

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38
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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39
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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40
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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41
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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42
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)

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43
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

44
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

45
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

46
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)

47
Q

what type of psychosocial intervention is recommended for fear of flying

A

group CBT

computer generated VR exposure

(bibliotherapy less effective)

48
Q

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

A

fear of flying

fear of heights

claustrophobia

arachnophobia

49
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

50
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

51
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

52
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

53
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)

54
Q

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

A

no

55
Q

what is the estimated lifetime prevalence of social anxiety disorder

A

8-12% internationally

(higher rates in developed vs developing countries)

56
Q

what is the mean age of onset of social anxiety disorder

A

12 years old

57
Q

what is the typical course of social anxiety disorder

A

chronic and unremitting

58
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

59
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

60
Q

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

A

similar

?changes persist long with CBT

61
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

62
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

63
Q

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

A

seems to be psychotherapy

64
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

65
Q

list second line agents for social anxiety disorder + mnemonic

A

All Bros Can Carry Giant Pigs

Alprazolam

Bromazepam

Citalopram

Clonazepam

Gabapentin

Phenelzine

66
Q

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

A

clonazepam

pindolol

67
Q

are there any first line adjunctive therapies for social anxiety disorder

A

no–> only third line

68
Q

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

A

abilify

buspirone

paroxetine

risperidone

69
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

70
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

71
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

72
Q

is quetiapine recommended for treatment of social anxiety disorder

A

no

73
Q

is buspirone recommended for treatment of social anxiety disorder

A

no

74
Q

is citalopram recommended for treatment of social anxiety disorder

A

second line

75
Q

is gabapentin recommended for social anxiety disorder

A

second line

76
Q

is phenelzine recommended for social anxiety disorder

A

second line

77
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)

78
Q

is st johns wort recommended for treatment of social anxiety disorder

A

no

failed to demonstrate superiority over placebo

79
Q

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

A

no

80
Q

what is the estimated lifetime prevalence of GAD

A

about 6%

81
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

82
Q

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

A

10-14 years

83
Q

what % of those with GAD report painful physical symptoms

A

60-94%

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

84
Q

what medical syndromes have elevated risk in those with GAD

A

pain syndromes

HTN

CV and gastro conditions

85
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

86
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

87
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

88
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

89
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)

90
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)

91
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

92
Q

name a second line adjunctive agent for treatment of GAD

A

pregabalin

93
Q

name 4 third line adjunctive agents for treatment of GAD

A

aripiprazole

olanzapine

quetiapine/quetiapine XR

risperidone

94
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)

95
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

96
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)

97
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?

98
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

99
Q

what neurostimulation therapy may be beneficial for treatment of GAD

A

rTMS as monotherapy or adjunctive to SSRI

100
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

101
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

102
Q

maternal anxiety disorders are associated with which 3 adverse pregnancy outcomes

A

elective c section

premature delivery

shorter gestational age

*however, a meta analysis found no relationship between anxiety symptoms per se and adverse pregnancy outcomes

103
Q

maternal anxiety and related disorders have been associated with what challenges/adverse outcomes with regard to parenting

A

mothers with anxiety and related disorders may be:

-less promoting of psychological autonomy

-associated with behavioural/emotional problems in kids

-subsequent development of anxiety in the kid

104
Q

what is the risk associated with prenatal benzo exposure

A

oral cleft increased risk (absolute risk is small… another case control study did not find this association)

there is risk of neonatal withdrawal or toxicity syndrome

*no increased risk found of major malformations or cardiac defects

105
Q

what are the most common phobias reported in pediatric populations

A

blood/injury/injection and animal fears

106
Q

anxiety and related disorders among younger patients are associated with high rates of what issues/disorders in addition

A

comorbid psych conditions

SUD

sleep problems

somatic symptoms

suicidality

problems with cognition/attention

problems with academic performance

problems with peer relationships

107
Q

is there a benefit to universal anxiety prevention programs for preventing childhood anxiety and related disorders? what about indicated prevention programs (targeted to children demonstrating highly anxious symptoms)?

A

both have evidence of benefit–> indicated programs have larger effect sizes than universal programs

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