BCPP Recertification Review
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| Anxiety Mimics | Cocaine, Steroids, anticonvulsants, antidepressants, antihypertensives, bronchodilators, arrhythmias, endocrine
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| GAD-7 | General Anxiety Disorder screen assesses severity self-rated 5-mild, 10-moderate, 15-severe
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| HAM-A | Assesses severity of anxiety, clinician rated, documents therapy response. 0-17 mild, 18-24 moderate, 25-30 severe
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| BAI | Beck Anxiety Inventory, measures severity, distinguishes from depression. 0-7 minimal, 8-15 mild, 16-25 moderate, 26-63 severe
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| PSWQ | Penn State Worry Questionnaire > or = 60 for GAD
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| SAS | Zung Self Rated Anxiety Scale, measures severity, 20-44 normal, 45-59 moderate, 60-74 moderate -severe, 75-80 extreme
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| Noradrenergic model GAD | HPA axis dysregulation. SNRI inhibit LC firing decrease NE activity and block effects of anxiogenic drugs
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| GABA receptor model GAD | GABA inhibitory effect on 5-HT, NE, and DA systems
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| Treatment Augmentation GAD | SGZ, BZD, Antihistamine, Buspirone, Pregabalin
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| FDA approved for GAD | Paroxetine, Escitalopram. Venlafaxine, Duloxetine, Hydroxyzine Buspirone
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| Not FDA approved for GAD | Sertraline, Citalopram, Imipramine, Trazodone, Mirtazapine, Bupropion, Vortioxetine, Vilazodone, Pregabalin, Tiagabine, SGA
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| BZD | Switching from short acting to long acting prior to taper not supported in the literature
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| BZD Drug Interactions | Enzyme Inducers (anticonvulsants) Inhibitors (Azoles, Mycins, Nefazodone, Fluvoxamine, Fluoxetine, Cimetidine, OCP's Diltiazem, Verapami, Nelfinavir, Indinavir, Ritonavir, Saquinavir.
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| Elderly | C/I Venlafaxine, BZD, Escitalopram (not effective) Paroxetine (ACH) SSRI(hyponatremia) Preferred - Sertraline, Citalopram, Lorazepam, Oxazepam.
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| 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)
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| PAS | Panic and Agoraphobia scale. monitor treatment efficacy, dual rated. Remission <11
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| SPRAS | Sheehan Patient Rated Anxiety Scale. assesses symptom severity 5 point scale weighted toward somatic symptoms
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| PRIME-MD | The Primary Care Evaluation of Mental Disorders Anxiety Module. clinician rated. used on primary care.
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| 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
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| FDA Approved for PD | Fluoxetine, Sertraline, Paroxetine (all SSRI effective except Fluvoxamine) Venlafaxine (Duloxetine effective) Clonazepam, Alprazolam. ( CBT and BDZ equivalent for augmentation)
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| Not FDA Approved for PD | TCA - Imipramine Clomipramine studied. Mirtazapine. Phenelzine
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| 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.
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| 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.
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| 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
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| 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.
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| 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
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| PSS-I | PTSD Symptom Scale Interview. Trained lay interviewer, assesses severity of Sx over 1 week. 0 -3. 0=never, 3= 5x or greater
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| 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.
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| 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
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| 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
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| PTSD Treatment | 1st line = SSRI, SNRI, CBT. Mirtazapine, Augment with Prazosin. 2nd Line TCA (includes Mirtazapine and Nefazodone) 3rd Line SGA Olanzapine, Risperidone
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| PTSD Sleep Issues | Trazodone, Nefazodone, Mirtazapine, Olanzapine, Quetiapine, Low Dose TCA, and Zolpidem show some efficacy
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| Non pharmacological PTSD Treatment | CBT, EMDR, Exposure Therapy, Anxiety Management Techniques,
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| FDA Approved for PTSD Treatment | Paroxetine, Sertraline
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| Non FDA Approved for PTSD Treatment | Fluoxetine, Citalopram, Fluvoxamine, Escitalopram, Venlafaxine, Imipramine, Amitriptyline, Mirtazapine, Phenelzine. Carbamazepine, Lamotrigine, Topiramate, Divalproex, Olanzapine, Quetiapine, Risperidone, Prazosin, Clonidine.
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| 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.
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| 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.
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| 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
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| OCI-R | Obsessive Compulsive Inventory 18 items, self rated, diagnosis and severity, targeted education. Range 0-72. w/6 subscales rated 0-12
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| 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
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| Pathophysiology of OCD | 5-HT and DA transmission abn. Increased activity in orbitofrontal cortex, limbic structures, caudate, and thalamus, possible glutaminergic abn
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| 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
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| Non Pharmacologic Tx of OCD | CBT, DBS, Surgery
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| FDA Approved for OCD | Fluoxetine, Fluvoxamine, Sertraline, Paroxetine, Clomipramine (Paroxetine, Fluoxetine and Fluvoxamine inhibit metabolism, serum level of drug + metabolite < 500 ng/ml)
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| Non FDA Approved for OCD | Escitalopram (inc efficacy over Paroxetine) Venlafaxine, Haloperidol (augment fluvoxamine, add propranolol) Risperidone
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| 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
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| Special populations OCD | Pregnant & nursing - Clomipramine. Children - Fluoxetine, Fluvoxamine, Sertraline, Clomipramine. Elderly-CI for Clomipramine
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| 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.
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| 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.
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| 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.
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| 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
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| 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.
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| Etiology/Risk Factors SAD | Psychiatric co-morbidity, early onset of phobias, separation anxiety, life stressors, environment. Genetics
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| 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.
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| 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. `
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| 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
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| 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
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| FDA approved for SAD | Paroxetine, Sertraline, Venlfaxine XR
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| Non-FDA Approved for SAD | Fluoxetine. Citalopram, Escitalopram Fluvoxamine, Mirtazapine, Clonazepam, Anticonvulsants, Tx resistance = Phenelzine
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| Monitoring in SAD | Sexual SE's Efficacy,
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| 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
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| 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
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| Separation Anxiety Disorder | Fear of loss separation from major attachment figure. Irrational fears, somatic complaints. Not explained by any other disorder
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| 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.
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| Adult Separation Anxiety Questionnaire | Examines sx after 18 years of age with Likert scale. 0-never 3-often. Score >16 definitive diagnosis.
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| 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.
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| 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
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