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Treating Resistant Anxiety Disorders ( Resource: healthyminds)

Treating Resistant Anxiety Disorders ( Resource: www.healthyminds.org). Lorrin M. Koran, M.D. Professor of Psychiatry, Emeritus Stanford University Medical Center. Panic Disorder without Agoraphobia: Diagnostic Criteria. Recurrent unexpected panic attacks

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Treating Resistant Anxiety Disorders ( Resource: healthyminds)

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  1. Treating Resistant Anxiety Disorders(Resource: www.healthyminds.org) Lorrin M. Koran, M.D. Professor of Psychiatry, Emeritus Stanford University Medical Center

  2. Panic Disorder without Agoraphobia:Diagnostic Criteria • Recurrent unexpected panic attacks • ≥ 1 month of worry re recurrence, implications, consequences • ≥ 1 month of changed behavior • Not due to substance or medical disorder • Not better accounted for by other psych dx, e.g., PTSD, OCD, social phobia

  3. Epidemiology of Panic Disorder • Prevalence: 1.6%-2.2%, F/M = 2/1 • Age at onset typically 20s • Runs in families: • Risk = 4-7x higher in first degree relatives • Comorbidities: • Major depression - 50%-60% • Alcohol/substance • GAD, OCD, PTSD • Bipolar I and II - 11%-22%

  4. Caffeinism Hyperthyroidism COPD Stimulant abuse Hypoparathyroidism Vestibular problem TLE Cardiac arrhythmia Steroids Bronchodilators Pheochromocytoma Hypoglycemia Panic Disorder: Differential Dx

  5. First-line Treatments for Panic Disorder • CBT (~ 65% much, very much improved) • SSRI (50-65% panic free, vs 40-55% placebo) • Sertraline ≥ 100 mg. Paroxetine 40 mg > 20 mg • Citalopram 20-30 mg > 40-60 mg (drop outs) • Benzodiazepine (60-75% panic free) • Add CBT later to SSRI (starting both simultaneously may lead to poorer long-term outcome) • Patient education

  6. Possible Treatments for Rx-Resistant Panic Disorder • Add to an SSRI: • CBT (controlled trials) • high-potency benzodiazepine (dbl.blind trials) • Pindolol (2.5 mg tid) (open trial) • Pramipexole (0.251.5 mg/d) (cases) • Switch to a TCA (imipramine 75-150 mg) • Switch to mirtazapine (1 small trial) • Add or switch to an atypical antipsychotic

  7. Generalized Anxiety Disorder:Diagnostic Criteria • Excessive worry re many events/activities • Difficult to control (unlike normal worry) • ≥ 50% of days in past 6 months • ≥ 3 of: • Muscle tension, restlessness, mental tension, • Fatigue, irritability, poor concentration • Causes signif. distress or impairment

  8. Epidemiology of Generalized Anxiety Disorder • Prevalence 1 year: 3%, lifetime: 5% • F/M = 2/1 • Onset ≥ 50% in childhood/adolescence • Less than 50% remit without Rx • About 8% of patients in primary care • Comorbidities: • Major depression 63%, dysthymia 40% • Panic disorder, Social Anxiety Disorder, OCD • Sedative, anxiolytic drug abuse • Fibromyalgia, irritable bowel, chest pain, headache

  9. First-line Treatments for Generalized Anxiety Disorder • SSRI - sexual SEs • SNRI - venlafaxine, duloxetine • Benzodiazepines - differences among them • Buspirone - onset 2-4 weeks. 20-60 mg • Hydroxyzine - 50 mg/day, 12-week trial • CBT - self-monitor; relaxation; cognitive therapy; rehearse skills via imagery

  10. Possible Treatments for Rx-Resistant Generalized Anxiety Disorder • Take a caffeine history • Consider treatment alliance, comorbid conditions, adherence, secondary gain, stressors, family • Add CBT to drug or vice versa (sparse data) • Add an SSRI or SNRI to a benzodiazepine (?) • Add to an SSRI or SNRI: • A benzodiazepine (experts suggest) • pregabalin (dbl-blnd studies) • an atypical antipsychotic (case reports)

  11. Social Anxiety Disorder:Diagnostic Criteria • Marked, persistent fear of social situations • Fear of embarrassment, humiliation • Excessive anxiety in the feared situation • Avoids, or endures with great distress • Impaired function or marked distress • If under age 18, duration ≥ 6 months • Not due to BDD, panic, stuttering, anorexia

  12. Epidemiology of Generalized Social Anxiety Disorder • Prevalence 1 yr: 8%; lifetime 13% • F/M = 1.4/1 • Onset usually childhood/adolescence • Spontaneous remission in only 20% • Comorbidities • Major depression - 60% lifetime • Agoraphobia - 47% • Alcohol abuse - 25%-35% • GAD - 20%, panic disorder - 10% • Body dysmorphic disorder - 11%

  13. First-line Treatments for Social Anxiety Disorder • SSRI (50%-80% response [≥ 50%  in LSAS score]) • Venlafaxine (44%-69% response) • Benzodiazepine (doesn’t Rx comorbid MDD) • CBT (50%-66% response) • Individual format better than group format • ? More durable than meds after discontinuation • Doesn’t add to SSRI efficacy in studies, but may help a given individual

  14. Possible Treatments for Rx-Resistant Social Anxiety Disorder • Add to an SSRI or SNRI (expert opinion): • CBT (individual, not group) • A benzodiazepine • Gabapentin or Pregabalin • Switch to an MAOI (controlled trial)

  15. Evidence for Anticonvulsants in Anxiety DisordersMula et al., J Clin Psychopharmacol 2007;27:263-272

  16. APA Practice GuidelineWork Group on OCD • Lorrin M. Koran, M.D., Chair • Gregory L. Hanna, M.D. • Eric Hollander, M.D. • Gerald Nestadt, M.D. • Helen Blair Simpson, M.D., Ph.D. APA Staff • Robert Kunkle, M.A., Senior Program Manager • Amy B. Albert, B.A., Project Manager • Laura J. Fochtmann, M.D., Medical Editor

  17. Disclosures • L. Koran, M.D. • Cypress Bioscience, Eli Lilly, Forest Laboratories, Jazz Pharmaceuticals, Ortho McNeil, Somaxon, • E. Hollander, M.D. • Abbott, Eli Lilly, Forest Laboratories, GlaxoSmithKline, Janssen, Pfizer, Somaxon, Wyeth

  18. APA Guideline for Obsessive-Compulsive Disorder:Psychiatric Management • Establish a therapeutic alliance. • Assess symptoms and differentiate them from those of other disorders. • Consider using rating scales. • Enhance the safety of the patient and others. • Set treatment goals (e.g., to improve symptoms, functioning, QOL; enhance cooperation, coping; educate the patient and family). • Enhance treatment adherence.

  19. Choosing an Initial Treatment • First-line treatments: CBT, SRI, or SRI + CBT. • CBT alone is recommended for a patient who is not too depressed, anxious, or severely ill to cooperate with treatment, or who prefers not to take medications. • An SRI alone is recommended for a patient who has previously responded well to a given drug or who prefers treatment with an SRI alone.

  20. Combined Treatment • More effective than monotherapy for some patients, but not necessary for all. • Consider for patients with an unsatisfactory response to monotherapy, for those with co-occurring psychiatric conditions for which SRIs are effective, and for those who wish to limit the duration of SRI treatment. • Also consider for patients with severe OCD.

  21. Comorbid Conditions in OCD Treatment Implications e.g., of tics/Tourette’s

  22. Axis I Comorbidity in OCD Subjects Pinto A, et al. J Clin Psychiatry. 2006;67:703-711.

  23. Pharmacotherapy for OCD • Clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline are FDA-approved. • An SSRI is preferred for a first medication trial because the SSRIs have a less troublesome side effect profile than clomipramine. • All SSRIs (including citalopram and escitalopram) appear to be equally effective. Consider side effects, drug interactions, past treatment response, and co-occurring general medical conditions.

  24. CBT and Other Psychotherapies • CBT utilizing primarily behavioral techniques such as exposure and response prevention (ERP) is recommended because it has the best evidentiary support. • Some data support Cognitive Therapy. • Psychodynamic psychotherapy may help patients overcome resistance to treatment or address interpersonal consequences of OCD. • Motivational interviewing and family therapy may be useful.

  25. Implementing Pharmacotherapy • Initiate at the dose recommended by the manufacturer and titrate to the maximum tolerated dose. • Continue for 8-12 weeks, including 4-6 weeks at a maximum tolerated dose. • Manage side effects (e.g., insomnia, fatigue, sweating, bruxism, sexual dysfunction). • Follow-up may vary from a few days to 2 weeks after starting a new medication.

  26. Implementation of CBT • The literature and expert opinion suggest that an adequate trial for most patients is 13-20 weekly sessions with daily homework (or 3 weeks of weekday daily CBT). • CBT can be delivered in individual, group, or family formats, with session lengths from <1 hour to 2 hours. • Consider booster sessions after response. • Self-help treatment guides are OK to use. • Refer patients to www.ocfoundation.org.

  27. Changing Treatment: General Principles • First treatments rarely produce freedom from all OCD symptoms. • Patients may be willing to accept residual symptoms. But consider whether depressed mood is diminishing hopefulness or illness is associated with secondary gain. • Consider contribution of other factors such as problems in the therapeutic alliance, interference of co-occurring conditions, inadequate adherence, psychosocial stressors, or family accommodation.

  28. Changing Treatment: Strategies • Augment SSRI with CBT (or CT) or vice versa. • Augment SSRI with an atypical antipsychotic. • Switch to a different SSRI or to clomipramine. • Switch to venlafaxine or to mirtazpine. • Augment with buspirone, once-weekly morphine, inositol, or a glutamate antagonist. • Switch to d-amphetamine, tramadol, ondansetron, or an MAOI. • Consider rTMS, deep brain stimulation, ablative neurosurgery.

  29. Discontinuing Treatment • Continue medication for 1-2 years, then consider a gradual taper (10%-25% q 1-2 months). • Follow successful CBT with monthly booster sessions for 3-6 months or more. • Relapse rates are high. Most patients require continued treatment of some form. • Some data suggest “relapse” 4-6 months after CBT is less likely than after medication has been stopped.

  30. Additional Information Available in the Full-Text Guideline • Disease definition • Epidemiology • Natural history and course • Genetics • Review of evidence regarding all treatments • Suggestions for future research Published in Am J Psychiatry, July 2007, and www.psychiatryonline.com.

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