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Guidelines Flashcards

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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
What meds are second line for GAD?
citalopram fluoxetine mirtazapine trazodone
26
Adjunctive meds for GAD?
second line is pregabalin third line is aripiprazole, olanzapine, quetiapine, risperidone
27
Whats better for GAD - meds, therapy, both?
CBT = meds combo > CBT alone at post treatment, but not at 6 month follow up no recommendations to routinely combine
28
what psychotherapy is best for GAD?
CBT (group = individual, but earlier improvement with individual) maybe some evidence for relaxation therapy, balneotherapy, psychodyamic, ACT, adjunctive MBCT
29
Any biological therapies for GAD?
rTMS is effective as monotherapy or as adjunct to SSRIs
30
First line med treatments for OCD?
5 SSRIs - EFFPS
31
Second line med treatments for OCD?
citalopram venlafaxine mirtazapine clompiramine
32
Adjunctive therapy for OCD?
first line: abilify, risperidone second line: memantine, quetiapine, topiramate third line: ketamine, mirtaz, NAC, olanzapine, pregabaline, haldol, ondansetron
33
What's better for OCD - meds, therapy, or both?
Combo > meds alone Combo is NOT SUPERIOR to CBT alone CBT = or > meds adding CBT to meds enhances response, reduces relapse rates
34
What's the best psychotherapy for OCD?
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
First line meds for PTSD?
3 SSRIs --> FtPS venlafaxine
36
Second line meds for PTSD?
fluvoxamine mirtazapine phenelzine
37
Third line for PTSD?
bupropion duloxetine escitalopram many others - abilify, quetiapine, risperidone, lamotrigine, buspirone, amitriptyline, memantine.. etc.
38
Adjunctive therapy for PTSD?
second line: risperidone, olanzapine, zopiclone third line: quetiapine, abilify, gabapentin, pregabalin, clonidine, keppra
39
what med is interestingly NOT recommended in PTSD
citalopram also olanzapine and divalproex
40
Are meds or therapy better for PTSD?
mixed findings. both effective. maybe psychotherapy is less effective than meds.
41
what psychotherpay is recommended in PTSD?
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
meds recommended in pregnancy for anxiety disorders?
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
benzos in pregnancy?
maybe increased risk of oral cleft defects, neonatal withdrawal/toxicity.
44
SSRIs in breastfeeding?
sertraline, paroxetine lowest amounts
45
antipsychotics in pregnancy?
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
Medication differences for children in anxiety disorders?
fluoxetine AND fluvoxamine are recommended in ALL -- separation, SAD, GAD, OCD (except panic and PTSD)
47
Psychotherapy interventions for acute mania
nil
48
psychotherapy interventions for acute depression -- first, second third line
No first line Second line -- CBT, Family focused therapy third line -- IPSRT (interpersonal and social rhythm therapy)
49
Psychotherapy for maintenance of bipolar disorder - first, second third line
first line = psychoeducation second line = CBT and family focused therapy third line = IPSRT - interpersonal and social rhythm therapy and peer support
50
what medications are first line for Bipolar 1 acute mania (monotherapies)?
(in order you should try them): lithium quetiapine divalproex asenapine aripiprazole palipderidone >6mg risperidone cariprazine
51
What medications are first line for Bipolar 1 acute mania (combination therapies)?
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
What medications are second line for bipolar 1 acute mania?
Olanzapine Carbamazapine Olanzapine + Li/DVP Lithium + DVP Ziprasidone Haloperidol ECT (80% will respond)
53
Reasons to do lithium? Reasons not to do lithium?
classic euphoric grandiose mania, family history of bipolar Not choose in: mixed features, comorbid substance use
54
Reasons for choosing divalproex
maybe better in dysphoric mania, predominant irritable or dysphoric mood, comorbid substance abuse, history of head trauma, mixed features
55
if there's psychosis and mania, what meds should you choose?
Probably antipsychotic + Li/DVP
56
First line treatments for Bipolar 1 acute depression?
Quetiapine Lurasidone + Li/DVP Lithium Lamotrigine Lurasidone Lamotrigine (adj) *don't choose lamotrigine if need rapid response
57
second line treatments for bipolar 1 acute depression?
Divalproex SSRIs/bupropion (adj) ECT Cariprazine Olanzapine-fluoxetine
58
what to not choose for bipolar 1 acute depression?
abilify antidepressant monotherapy
59
best meds for anxious distress in acute depression bipolar 1?
olanzapine-fluoxetine, lurasidone, asenapine
60
if psychotic in acute depression bipolar 1, how to treat?
ECT and/or antipsychotics
61
how to treat rapid cycling in bipolar 1?
treat hypothyroidism do not use antidepressants treat substance abuse (also associated with rapid cycling)
62
How to treat bipolar 1 in the maintenance phase?
Generally continue meds that worked in acute, except for adjunctive antidepressants are not recommended due to manic switch risk
63
What meds are first line for Bipolar 1 maintenance?
Lithium Quetiapine Divalproex Lamotrigine Asenapine Quetiapine + LI/DVP Aripiprazole + LI/DVP Aripiprazole
64
What meds are second line for Bipolar I maintenance?
Olanzapine Risperidone LAI Risperidone LAI (adj) Carbamazepine Paliperidone >6mg Lurasidone + Li/DVP Ziprazidone + Li/DVP
65
What is first line for Bipolar II acute depression?
Only quetiapine
66
What is second line for Bipolar II acute depression?
Lithium Lamotrigine Bupropion (adj) ECT Sertraline (if pure, non-mixed depression) venlafaxine (if pure, non-mixed depression)
67
What is first line for bipolar II maintenance?
quetiapine lithium lamotrigine
68
what is first line for bipolar II acute hypomania?
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
What does OCP do to lamotrigine?
causes lower levels
70
first line for children/adolescents with acute mania medications?
use lithium, risperidone, abilify, asenapine, and quetiapine
71
children/adolescents with acute bipolar depression - first line treatment?
lurasidone first line, and lithium/lamotrigine as second line
72
Older adults - first line in acute mania?
LI, DVP as first line, then quetiapine is second-line
73
special considerations for substance use (alcohol, stimulants, opioids) and bipolar, what to do with medications?
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
how to treat comorbid anxiety and bipolar?
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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