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Anxiety Disorders

BCPP Recertification Review

Anxiety Mimics Cocaine, Steroids, anticonvulsants, antidepressants, antihypertensives, bronchodilators, arrhythmias, endocrine
GAD-7 General Anxiety Disorder screen assesses severity self-rated 5-mild, 10-moderate, 15-severe
HAM-A Assesses severity of anxiety, clinician rated, documents therapy response. 0-17 mild, 18-24 moderate, 25-30 severe
BAI Beck Anxiety Inventory, measures severity, distinguishes from depression. 0-7 minimal, 8-15 mild, 16-25 moderate, 26-63 severe
PSWQ Penn State Worry Questionnaire > or = 60 for GAD
SAS Zung Self Rated Anxiety Scale, measures severity, 20-44 normal, 45-59 moderate, 60-74 moderate -severe, 75-80 extreme
Noradrenergic model GAD HPA axis dysregulation. SNRI inhibit LC firing decrease NE activity and block effects of anxiogenic drugs
GABA receptor model GAD GABA inhibitory effect on 5-HT, NE, and DA systems
Treatment Augmentation GAD SGZ, BZD, Antihistamine, Buspirone, Pregabalin
FDA approved for GAD Paroxetine, Escitalopram. Venlafaxine, Duloxetine, Hydroxyzine Buspirone
Not FDA approved for GAD Sertraline, Citalopram, Imipramine, Trazodone, Mirtazapine, Bupropion, Vortioxetine, Vilazodone, Pregabalin, Tiagabine, SGA
BZD Switching from short acting to long acting prior to taper not supported in the literature
BZD Drug Interactions Enzyme Inducers (anticonvulsants) Inhibitors (Azoles, Mycins, Nefazodone, Fluvoxamine, Fluoxetine, Cimetidine, OCP's Diltiazem, Verapami, Nelfinavir, Indinavir, Ritonavir, Saquinavir.
Elderly C/I Venlafaxine, BZD, Escitalopram (not effective) Paroxetine (ACH) SSRI(hyponatremia) Preferred - Sertraline, Citalopram, Lorazepam, Oxazepam.
PDSS Panic Disorder Severity Scale, assesses severity, Clinician rated. -agoraphobia (0-1 nl, 2-5 borderline, 6-9 slightly ill, 10-13 moderately ill, >14 markedly ill) +agoraphobia (3-7 borderline, 8-10 slightly ill, 11-15 moderately ill, >16 markedly ill)
PAS Panic and Agoraphobia scale. monitor treatment efficacy, dual rated. Remission <11
SPRAS Sheehan Patient Rated Anxiety Scale. assesses symptom severity 5 point scale weighted toward somatic symptoms
PRIME-MD The Primary Care Evaluation of Mental Disorders Anxiety Module. clinician rated. used on primary care.
Panic Disorder Neurobiological Reduced volumes amygdala and temporal lobe. Lower creatine and phosphocreatine metabolites in the medial temporal lobe. Decreased cerebral glucose metabolism in amygdala, hippocampus, thalamus, and brain stem. Reductions in central BZD receptor density
FDA Approved for PD Fluoxetine, Sertraline, Paroxetine (all SSRI effective except Fluvoxamine) Venlafaxine (Duloxetine effective) Clonazepam, Alprazolam. ( CBT and BDZ equivalent for augmentation)
Not FDA Approved for PD TCA - Imipramine Clomipramine studied. Mirtazapine. Phenelzine
Definition of Remission of PD Attack free, PDSS < or = 3 and no individual score >1. no or mild agoraphobia, no or mild anxiety (HAM-A < or = 10) No fx disability, no depression.
PTSD Diagnosis (May be delayed expression 6 months) Recurrent memories, dreams, flashbacks, prolonged psychological distress at cues, marked physiological rxn to cues, Avoidance Stimuli, Neg impact on mood-cognition, Alterations reactivity and hyperarousal >1 month. Disassociation or Depersonalization.
CAPS Clinician Administerd PTSD scale. Gold Standard. Assesses all Sx. Children = CAPS-CA. Takes 45-60 min. Score = Sx frequency of 1 or more, Intensity of 2 or more
PTSD Checklist 17 items, self report, 5 point scale. Cut off 47 for civilians, 50 for military. Minimum change of 5 points for response, 10 points for clinically meaningful response.
IES-R Impact of Event Scale-Revised. Targets 14 of 17 symtpoms. 7 additional related to hyperarousal, self rated, >2 weeks post event or recovery assessment. 5 point scale range 0-88. subscale scores
PSS-I PTSD Symptom Scale Interview. Trained lay interviewer, assesses severity of Sx over 1 week. 0 -3. 0=never, 3= 5x or greater
Prevalence and Risk of PTSD Prevalence 1 in 27. Risk Pre = demographics, trauma hx, psych hx. Peri = severity, threat to life, response, dissociation. Post= social support, dysfunction, subsequent stressors.
Clinical Course of PTSD Peaks days to weeks after event, gradual decline over 1yr. Sx with tx = 36 months. no tx. = 5 yrs. 1/3 chronic Sx. Sequelae = personality change, fx impairment, Suicide, SA
Pathophysiology PTSD Dec Cortisol d/t adrenal exhaustion, HPA Axis - down regulation of beta and alpha-2 adrenergic receptors, increased reactivity to alpha-2 antagonist Yohimbine. Alpha-1 dysregulation = sleep and startle, Alpha-2 appropriate response emotional stim
PTSD Treatment 1st line = SSRI, SNRI, CBT. Mirtazapine, Augment with Prazosin. 2nd Line TCA (includes Mirtazapine and Nefazodone) 3rd Line SGA Olanzapine, Risperidone
PTSD Sleep Issues Trazodone, Nefazodone, Mirtazapine, Olanzapine, Quetiapine, Low Dose TCA, and Zolpidem show some efficacy
Non pharmacological PTSD Treatment CBT, EMDR, Exposure Therapy, Anxiety Management Techniques,
FDA Approved for PTSD Treatment Paroxetine, Sertraline
Non FDA Approved for PTSD Treatment Fluoxetine, Citalopram, Fluvoxamine, Escitalopram, Venlafaxine, Imipramine, Amitriptyline, Mirtazapine, Phenelzine. Carbamazepine, Lamotrigine, Topiramate, Divalproex, Olanzapine, Quetiapine, Risperidone, Prazosin, Clonidine.
Special populations PTSD Tx pregnant and lactating, children and adolescents with CBT. Women have 4 fold longer course of illness than men as well as higher incidence.
OCD Diagnosis Obsessions - persistent recurrent thoughts images urges. Compulsions - repetitive behaviors to reduce anxiety. Have one or both. Marked distress and interfere nl routine. Ex. Obsession - contamination, associated Compulsion - cleaning.
Y-BOCS Yale Brown Obsessive Compulsive Scale. 10 items measures severity over last 7 days, clinician and self rated. 32-40 Extreme, 24-31 Severe, 16-23 Moderate, 8-15 Mild, 0-7 Subclinical
OCI-R Obsessive Compulsive Inventory 18 items, self rated, diagnosis and severity, targeted education. Range 0-72. w/6 subscales rated 0-12
Etiology/Risk for OCD Genetics, Evironment, PANDAS in kids (Streptococcal ABs cross react with basal ganglia - tx SSRI, IGG, T&A, Steroids) 50%Sudden onset after pregnancy, death. Delay to tx secret. Co-morbid depression in one third. Present to PCP with chapped hands
Pathophysiology of OCD 5-HT and DA transmission abn. Increased activity in orbitofrontal cortex, limbic structures, caudate, and thalamus, possible glutaminergic abn
Treatment of OCD 1st line SSRI CBT, 2nd Line Clomipramine, 3rd Line SSRI augmentation with SGA, Haloperidol, CBT, Clomipramine, Other Lithium, Mood Stabilizer,Buspar, Pindolol, Ondansetron, Nicotine, Tryptophan, Morphine
Non Pharmacologic Tx of OCD CBT, DBS, Surgery
FDA Approved for OCD Fluoxetine, Fluvoxamine, Sertraline, Paroxetine, Clomipramine (Paroxetine, Fluoxetine and Fluvoxamine inhibit metabolism, serum level of drug + metabolite < 500 ng/ml)
Non FDA Approved for OCD Escitalopram (inc efficacy over Paroxetine) Venlafaxine, Haloperidol (augment fluvoxamine, add propranolol) Risperidone
Duration of tx for OCD Longer than 1 year. 1-2 years, high relapse rate, life-long therapy recommended after 2-4 relapses or 3-4 less severe relapses
Special populations OCD Pregnant & nursing - Clomipramine. Children - Fluoxetine, Fluvoxamine, Sertraline, Clomipramine. Elderly-CI for Clomipramine
Studies in OCD Higher Dose SSRI may be more effective. Pediatric partial response to SSRI addition of CBT increased efficacy. SGA's may be useful in pts with symmetry, hoarding or ordering.
Diagnosis of SAD Fear/avoidance of social situations out of context. Lasts for 6 months or longer, clinically significant impairment or distress in functional areas. Specific for performance only, also generalize or non-generalized.
LSAS Leibowitz Social Anxiety Scale. Clinician rated used to diagnose and assess. Fear and Avoidance individually rated 1-3 for severity. >95 very severe, 80-95 severe, 65-80 marked, 55-65 moderated. Response score =50. Remission score = 30.
SPAI Social Phobia and Anxiety Inventory. For 14yo and over. Assesses somatic sx, behavior, cognition. Self rated. Diff dx. PD, Agoraphobia, and social phobia. Subscales for agoraphobia and social phobia. Subtract Ag score for pure Social phobia score
SPIN Screening assessing severity and tx. outcome. Self Rated. >51 very severe, 41-50 severe, 31-40 moderate, 21-30 mild,<20 none. Responsive to change over time.
Etiology/Risk Factors SAD Psychiatric co-morbidity, early onset of phobias, separation anxiety, life stressors, environment. Genetics
Clinical Course SAD Onset 14-16 yrs, typical delay 10 yrs to tx. 70-80% hx of concurrent anxiety, depression, or SA. 20% have SA. Without tx, chronic, unremitting, lifelong. Best prognosis earl detection tx. Pts. tend toward lower demographics.
Pathophysiology SAD Nongeneralized subtype NE dysfunction. Generalized subtype DA dysfx. - decreased receptor binding, low levels of metabolites, high incidence in Parkinsons, Emergence of SAD during antipsychotic tx. 5-HT2 receptors hypersensitive. `
Treatment SAD 1st line SSRI or CBT. Pharmacotherapy x 10-12 weeks at max dose before conclude inadequate response. If no response another SSRI or Venlafaxine. Limited evidence for augmentation in partial response. Phenelzine option for refractory
Non-pharmacologic Tx for SAD CBT, Exposure, Cognitive Restructuring for at 12 weeks. More effective individually than group. Similar efficacy to pharmacotherapy acutely. Gains maintained for 6-12 months persist longer than pharmacotherapy. Other = social skills training
FDA approved for SAD Paroxetine, Sertraline, Venlfaxine XR
Non-FDA Approved for SAD Fluoxetine. Citalopram, Escitalopram Fluvoxamine, Mirtazapine, Clonazepam, Anticonvulsants, Tx resistance = Phenelzine
Monitoring in SAD Sexual SE's Efficacy,
Special Populations SAD Children and Adolescents, Paroxetine, Fluvoxamine, Sertraline, Venlafaxine 6-17 yrs. BZD last line. Elderly - start low, go slow, Paroxtine avoided d/t ACH
Trial Data SAD SGA's effective in SAD, no difference in efficacy among agents. Phenelzine + CBGT more effective than either alone. SSRI to treat SAD in alcohol use disorder efficacious
Separation Anxiety Disorder Fear of loss separation from major attachment figure. Irrational fears, somatic complaints. Not explained by any other disorder
Severity Measure for Separation Anxiety Disorder - Child age 11-17 Assesses severity of symptoms. Child rated. 5 point scale, can range from 0-40. 0 -none 4-extreme. rated continuously through follow up.
Adult Separation Anxiety Questionnaire Examines sx after 18 years of age with Likert scale. 0-never 3-often. Score >16 definitive diagnosis.
Etiology Risk Factors Separation Anxiety Life Stressors, +Heritability. Most children free of sx as adults. Adult may not recall childhood onset but do recall sx.
Treatment Guidelines Separation Anxiety Family relationship assessment. CBT. Most effective CBT plus medication. None FDA approved in kids, but use SSRI. 2nd line SNRI, TCA, BZD. 16 wks to improvement. Duration of tx 1 year or longer
Created by: earls591



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