Anxiety disorders slides (1).pptx

PSYCHIATRY REVIEW:
ANXIETY, OBSESSIVE-
COMPULSIVE AND
TRAUMA-RELATED
DISORDERS

Which of the following statements regarding pharmacological
treatment of generalized anxiety disorder (GAD) in older adults (>
65 years old) is most accurate?
A. Antidepressants are generally ineffective.
B. Antidepressants are not recommended due to their side effect
profile.
C. Antidepressants are less effective than psychotherapy.
D. Antidepressants are not recommended due to risk of drug-drug
interactions.
E. Antidepressants are a first-line treatment.
QUESTION 1
Class responses
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QUESTION 1
Final answer?

A. Antidepressants are generally ineffective. (1)
profile.
C. Antidepressants are less effective than psychotherapy. (1)
interactions.
E. Antidepressants are a first-line treatment. (6)

ANSWER 1
Explanation

A. Antidepressants are generally ineffective.
profile.
C. Antidepressants are less effective than psychotherapy.
interactions.
E. Antidepressants are a first-line treatment.

The same treatments that are effective for anxiety in younger
persons are also effective in the elderly. Although both
pharmacotherapy and behavioral interventions are reasonably
effective, the weight of evidence suggests that there are higher
average treatment effects with pharmacological interventions.
Although side effects, drug interactions, and patient preferences
should be taken into account, in most elderly patients
pharmacotherapy is likely to be the first-line treatment
recommendation for anxiety disorders.
Pinquart M, Duberstein PR. Treatment of anxiety disorders in older adults: a
meta-analytic comparison of behavioral and pharmacological interventions. Am J
Geriatr Psychiatry. 2007; 15(8):639–651.
EXPLANATION

Compared with selective serotonin reuptake inhibitor (SSRI)
monotherapy, adjunctive use of benzodiazepines in combination
with an SSRI for the treatment of panic disorder is associated with:
A. worse outcomes following benzodiazepine taper.
B. more rapid stabilization.
C. higher dropout rates.
D. lower side effect burden.
QUESTION 2
Class responses
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QUESTION 2
Final answer?

A. worse outcomes following benzodiazepine taper. (2)
B. more rapid stabilization. (5)
D. lower side effect burden. (1)

ANSWER 2
Explanation

A. worse outcomes following benzodiazepine taper.
B. more rapid stabilization.
D. lower side effect burden.

According to The APA Practice Guideline for the Treatment of
Patients with Panic Disorder benzodiazepines may be used along
with antidepressants to help control symptoms until the
antidepressant takes effect. Recent studies suggest that adjunctive
benzodiazepine use confers a short-term benefit by reducing panic
symptoms. However, the advantage of the combination does not
continue and individuals receiving SSRI alone catch up to those
receiving the combination after the first few weeks of treatment.
The benefit of quicker stabilization should be weighed against the
possibility of an increased side-effect burden. Studies of
medication and psychosocial treatment have not shown a clear and
lasting advantage for this combination.
Goddard AW, Brouette T, Almai A, Jetty P, Woods SW, Charney D. Early
coadministration of clonazepam with sertraline for panic disorder. Arch Gen
Psychiatry. 2001 Jul;58(7):681–686.
EXPLANATION 2

QUESTION 3
A 23 year old man is the sole survivor of a fire aboard a crowded
plane. In the immediate aftermath of exposure to the trauma,
which of the following interventions is most likely to be successful
in preventing psychological sequelae?
A. Encourage him to imagine positive emotions.
B. Have the man ventilate about how he is feeling.
C. Normalize the stress reaction.
D. Prescribe a short-acting benzodiazepine.
E. Use critical incident debriefing.
Class responses
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QUESTION 3
Need a hint?

C. Normalize the stress reaction. (4)
D. Prescribe a short-acting benzodiazepine. (1)
E. Use critical incident debriefing. (3)

You’ll find the answer in:
Hobfoll SE, et al. Five essential elements of immediate and mid-
term mass trauma intervention: empirical evidence. Psychiatry.
2007; 70(4):283–315.
NEED A HINT?
Final answer?


ANSWER 3
C. Normalize the stress reaction.
D. Prescribe a short-acting benzodiazepine.
E. Use critical incident debriefing.

QUESTION 4
Patients with comorbid obsessive compulsive disorder (OCD) and
tic disorder most often exhibit which of the following patterns of
OCD symptoms?
A. Harm obsessions and checking compulsions
B. Cleanliness obsessions and washing compulsions
C. Symmetry obsessions and ordering compulsions
D. Unacceptability obsessions and religions compulsions
Class responses
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QUESTION 4
Need a hint?

OCD symptoms?
A. Harm obsessions and checking compulsions (1)
B. Cleanliness obsessions and washing compulsions (2)
C. Symmetry obsessions and ordering compulsions (5)

You’ll find the answer in…
Eapen, V, et al. The role of clinical phenotypes in understanding
the genetics of obsessive-compulsive disorder. J Psychosom
Res. 2006 Sep;61(3):359-64.
NEED A HINT?
Final answer?


ANSWER 4
OCD symptoms?
A. Harm obsessions and checking compulsions
B. Cleanliness obsessions and washing compulsions
C. Symmetry obsessions and ordering compulsions

QUESTION 5
A 45 year old patient requests medication to treat symptoms
consistent with generalized anxiety disorder (GAD). The patient
has a history of heavy drinking. Which of the following
medications would be most appropriate to prescribe?
A. Clonazepam
B. Bupropion
C. Quetiapine
D. Gabapentin
E. Venlafaxine
Class responses
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QUESTION 5
Final answer?

A. Clonazepam
B. Bupropion
C. Quetiapine
D. Gabapentin (2)
E. Venlafaxine (6)

ANSWER 5
A. Clonazepam
B. Bupropion
C. Quetiapine
D. Gabapentin
E. Venlafaxine
Explanation


The most appropriate option is venlafaxine, which is an efficacious
treatment for GAD. While benzodiazepines, such as clonazepam,
alprazolam, and diazepam, are effective in treating generalized
anxiety disorder (GAD), the risk of benzodiazepine abuse or
dependence among alcohol abusers limits their utility. Bupropion,
quetiapine and gabapentin are not first-line treatments for GAD.
Hoge EA, Ivkovic A, Fricchione GL. Generalized anxiety disorder: diagnosis and
treatment. BMJ. 2012;345:e7500.
EXPLANATION

QUESTION 6
Which of the following disorders must be considered in the
differential diagnosis of individuals with late-onset obsessive-
compulsive disorder (OCD), i.e. symptom onset after age 45?
A. Huntington’s disease
B. Major depressive disorder
C. Delusional disorder
D. Normal pressure hydrocephalus
E. Parietal lobe CVA
Class responses
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QUESTION 6
Need a hint?

A. Huntington’s disease (3)
C. Delusional disorder (1)
D. Normal pressure hydrocephalus (1)
E. Parietal lobe CVA (3)

van Duijn E, Kingma EM, Van der mast RC. Psychopathology in
verified Huntington's disease gene carriers. J Neuropsychiatry Clin
Neurosci. 2007;19(4):441-8.
Weiss, AP and Jenike, MA. Late-onset obsessive-compulsive
disorder: a case series. J Neuropsychiatry Clin Neurosci. 2000
Spring;12(2):265-8.
NEED A HINT?
Final answer?


ANSWER 6
Explanation

A. Huntington’s disease
C. Delusional disorder
D. Normal pressure hydrocephalus
E. Parietal lobe CVA

QUESTION 7
Deep brain stimulation (DBS) for treatment-refractory obsessive
compulsive disorder (OCD) typically targets which of the following
brain regions?
A. Subgenual cingulate gyrus
B. Nucleus basalis of Meynert
C. Subthalamic nucleus
D. Ventral striatum
E. Nucleus accumbens
Class responses
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QUESTION 7
Need a hint?

brain regions?
A. Subgenual cingulate gyrus (3)
C. Subthalamic nucleus (1)
D. Ventral striatum (2)
E. Nucleus accumbens (2)

Blomstedt P, Sjöberg RL, Hansson M, Bodlund O, Hariz MI. Deep
brain stimulation in the treatment of obsessive-compulsive
disorder. World Neurosurg. 2013;80(6):e245-53.
NEED A HINT?
Final answer?


ANSWER 7
Explanation

brain regions?
A. Subgenual cingulate gyrus
C. Subthalamic nucleus
D. Ventral striatum
E. Nucleus accumbens

QUESTION 8
A patient has been successfully treated with a selective serotonin
reuptake inhibitor (SSRI) for acute panic episodes. What is the
minimum length of time recommended for maintenance
pharmacotherapy for this patient?
A. 2–4 months
B. 6–12 months
C. 18 months
D. At least 24 months
Class responses
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QUESTION 8
Final answer?

A. 2–4 months
B. 6–12 months (8)
C. 18 months

ANSWER 8
Explanation

A. 2–4 months
B. 6–12 months
C. 18 months

The APA Practice Guideline Watch for the Treatment of Patients
with Panic Disorder recommends maintenance pharmacotherapy
for at least 6–12 months following acute treatment. Studies of
fluoxetine, paroxetine, sertraline, imipramine and clomipramine
have demonstrated a benefit of continuing medication for 6–12
months. Maintenance pharmacotherapy should be considered for
most patients as a means of preventing recurrence of panic
disorder symptoms and promoting continued symptom relief and
better functioning.
American Psychiatric Association Practice Guideline for the Treatment of
Patients with Panic Disorder (2009).
Choy, Yujuan, et al. Three-year medication prophylaxis in panic disorder: to
continue or discontinue? A naturalistic study. Comprehensive Psychiatry 48
(2007) 419–425
Roy-Byrne PP, Craske MG, Stein MG. Panic disorder. Lancet 2006; 368:1023 –1032
EXPLANATION

QUESTION 9
A bus carrying students from a local high school is swept down the
side of the mountain following a mudslide. Despite rescue
attempts, all the youth on the bus either die or are seriously
wounded. Based on prevalence data, which of the following groups
of individuals is most likely to develop posttraumatic stress
disorder (PTSD) after the disaster?
A. Family members
B. First responders
C. Guidance counselors
D. Classmates
E. Teachers
Class responses
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QUESTION 9
Final answer?

A. Family members
B. First responders (7)
D. Classmates (1)
E. Teachers

ANSWER 9
Explanation

A. Family members
B. First responders
D. Classmates
E. Teachers

In a systematic review of posttraumatic stress disorder following
disasters, the highest prevalence of PTSD was found among
survivors and first responders. The prevalence of PTSD among first
responders assessed following involvement in rescue, recovery and
cleaning efforts were especially high.
Neria Y, Nandi A, Galea S. Post-traumatic stress disorder following disasters: a
systematic review. Psychol Med. 2008; 38(4):467–480
EXPLANATION

QUESTION 10
Which of following patient characteristics most consistently
predicts poor response to behavioral therapy in obsessive
compulsive disorder (OCD)?
A. Earlier age of onset
B. Family accommodation
C. Contamination fears
D. Checking rituals
E. Comorbid depression
Class responses
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QUESTION 10
Need a hint?

B. Family accommodation (5)
D. Checking rituals
E. Comorbid depression (3)

Keeley, ML, et al. Clinical predictors of response to cognitive -
behavioral therapy for obsessive-compulsive disorder. Clin Psychol
Rev. 2008 Jan;28(1):118-30.
NEED A HINT?
Final answer?


ANSWER 10
B. Family accommodation
D. Checking rituals
E. Comorbid depression

QUESTION 11
Which of the following statements best describes the association
between posttraumatic stress disorder (PTSD) and the subsequent
emergence of a substance use disorder (SUD)?
A. Young adults with PTSD are about five times more likely to
develop an SUD compared to traumatized young adults without
PTSD.
B. Even in the absence of PTSD, a history of significant trauma is
associated with an increased risk of developing an SUD.
C. After controlling for factors such as sex, age and ethnicity, PTSD
confers no additional increased risk of developing an SUD
D. After controlling for factors such as childhood conduct problems
and risk taking, PTSD confers no additional increased risk of
developing an SUD
E. After controlling for factors such as family SES and years of
education, PTSD confers no additional increased risk of
developing an SUD Class responses
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QUESTION 11
Need a hint?

PTSD. (4)
associated with an increased risk of developing an SUD. (4)
developing an SUD
developing an SUD

Reed PL, Anthony JC, Breslau N. Incidence of drug problems in
young adults exposed to trauma and posttraumatic stress disorder:
do early life experiences and predispositions matter? Arch Gen
Psychiatry. 2007; 64(12):1435–1442.
NEED A HINT?
Final answer?


ANSWER 11
PTSD.
associated with an increased risk of developing an SUD.
developing an SUD
developing an SUD

QUESTION 12
According to the National Comorbidity Survey (NCS), which of the
following experiences is most frequently associated with
posttraumatic stress disorder (PTSD) in women in the U.S.?
A. Life-threatening accident
B. Combat exposure
C. Natural disaster
D. Sexual assault
E. Witnessing violence
Class responses
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QUESTION 12
Final answer?

B. Combat exposure
C. Natural disaster
D. Sexual assault (8)

ANSWER 12
Explanation

B. Combat exposure
C. Natural disaster
D. Sexual assault

In the NCS, which was carried out in the early 1990s, the most
common stressor precipitants for women were sexual assault with
physical attack, being threatened with a weapon, and childhood
physical abuse, in that order. Combat exposure was the most
common stressor for men. A recent review points out that PTSD
lifetime prevalence in the NCS was twice as high in women as men
and that combat exposure accounts for a significant proportion of
PTSD in U.S. men. It also emphasizes that the main PTSD burden in
the U.S. stems not from war but from criminal victimization, motor
vehicle accidents, intimate partner violence, and childhood
maltreatment. Women are more likely to have experienced sexual
abuse, and men are more likely to have encountered physical
violence, whether in the U.S. or while at war.
Kessler RC, et al: Posttraumatic stress disorder in the National Comorbidity
Survey. Arch Gen Psychiatry 1995; 52:1048–1060
EXPLANATION

QUESTION 13
A patient with obsessive compulsive disorder (OCD) experienced
significant residual symptoms during adequate trials of two
different selective serotonin reuptake inhibitors (SSRIs) in
combination with psychotherapy. The patient has not tried any
other medications. Which of the following is the most appropriate
next step in treatment?
A. Switch from current SSRI to another SSRI
B. Switch from current SSRI to clomipramine
C. Augment current SSRI with clonazepam
D. Augment current SSRI with lithium
E. Augment current SSRI with buspirone
Class responses
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QUESTION 13
Final answer?

B. Switch from current SSRI to clomipramine (8)

ANSWER 13
Explanation

B. Switch from current SSRI to clomipramine

Clomipramine is the next best medication to prescribe.
Clomipramine has substantial evidence to support its use in OCD,
but due to its side effect profile, it is not typically prescribed until
a patient has failed trials of two SSRIs (as in this case). Another
SSRI would not be a good choice given that the patient has already
failed therapeutic trials of two SSRIs. Augmentation with
benzodiazepines, lithium or buspirone has not consistently
demonstrated efficacy in OCD.
Fineberg, NA and Gale, TM. Evidence-based pharmacotherapy of obsessive-
compulsive disorder. Int J Neuropsychopharmacol. 2005 Mar;8(1):107-29.
EXPLANATION

QUESTION 14
Which of the diagnostic criteria for posttraumatic stress disorder
(PTSD) is rarely fully-endorsed in preschool children?
A. Disturbance of over one month
B. Re-experiencing
C. Avoidance/numbing
D. Increased arousal
E. Clinically significant impairment
Class responses
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QUESTION 14
Need a hint?

B. Re-experiencing (5)
C. Avoidance/numbing (2)
E. Clinically significant impairment (1)

Sheeringa MS, et al. New findings on alternative criteria for PTSD
in preschool children. J Am Acad Child Adolesc Psychiatry. 2003;
42(5):564–565
Friedman MJ. Finalizing PTSD in DSM-5: getting here from there
and where to go next. J Trauma Stress. 2013;26(5):548-56.
NEED A HINT?
Final answer?


ANSWER 14
B. Re-experiencing
C. Avoidance/numbing
E. Clinically significant impairment

QUESTION 15
Which of the following medication combinations for individuals
with obsessive-compulsive disorder (OCD) comorbid with tic
disorder is best supported by current evidence?
A. Fluoxetine plus clonazepam
B. Sertraline plus buspirone
C. Citalopram plus naltrexone
D. Fluvoxamine plus haloperidol
Class responses
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QUESTION 15
Final answer?

C. Citalopram plus naltrexone (1)
D. Fluvoxamine plus haloperidol (7)

ANSWER 15
Explanation

C. Citalopram plus naltrexone
D. Fluvoxamine plus haloperidol

Evidence indicates that individuals with OCD and comorbid tic
disorder respond better to the combination of an SSRI and
haloperidol. While SSRI’s are typical first-line treatments for OCD,
clonazepam has not consistently demonstrated efficacy for OCD.
There is no evidence to support the use of buspirone or
naltrexone.
Grados, M, and Riddle, MA. Do all obsessive-compulsive disorder subtypes
respond to medication? Int Rev Psychiatry. 2008 Apr;20(2):189-93.
Fineberg NA, Gale TM, Sivakumaran T. A review of antipsychotics in the
treatment of obsessive compulsive disorder. J Psychopharmacology 2006; 20:97 –
103. Reprinted in FOCUS: OCD summer 2007:3.
EXPLANATION

QUESTION 16
Patients with acute stress disorder have been shown in controlled
trials to be least likely to subsequently develop posttraumatic
stress disorder (PTSD) when treated with:
A. cognitive restructuring therapy.
B. exposure therapy.
C. systematic debriefing.
D. couples therapy.
Class responses
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QUESTION 16
Need a hint?

A. cognitive restructuring therapy. (2)
B. exposure therapy. (1)
C. systematic debriefing. (5)
D. couples therapy.

Bryant RA, et al. Treatment of acute stress disorder: a randomized
controlled trial. Arch Gen Psychiatry. 2008; 65(6):659–667
NEED A HINT?
Final answer?


ANSWER 16
A. cognitive restructuring therapy.
B. exposure therapy.
C. systematic debriefing.
D. couples therapy.

QUESTION 17
Current evidence best supports which of the following statements
about the relationship between social anxiety disorder (SAD) and
body dysmorphic disorder (BDD)?
A. All patients with BDD also meet criteria for SAD.
B. BDD is the most common psychiatric comorbidity among
patients with SAD.
C. BDD is most likely a form of SAD characterized by poor insight.
D. BDD is most likely a cultural variant of SAD.
E. SAD and BDD share a similar gender distribution, age of onset
and clinical course.
Class responses
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QUESTION 17
Final answer?

A. All patients with BDD also meet criteria for SAD. (1)
patients with SAD.
D. BDD is most likely a cultural variant of SAD. (1)
and clinical course. (6)

ANSWER 17
Explanation

A. All patients with BDD also meet criteria for SAD.
patients with SAD.
D. BDD is most likely a cultural variant of SAD.
and clinical course.

“Social anxiety disorder (SAD) and body dysmorphic disorder (BDD)
are two separate, but conceptually overlapping nosological
entities. […] SAD and BDD are highly comorbid, show a similar age
of onset, share a chronic trajectory, and show similar cognitive
biases for interpreting ambiguous social information in a negative
manner. Furthermore, research from treatment outcome studies
have demonstrated that improvements in SAD were significantly
correlated with improvements in BDD.” Individuals with SAD or
BDD have a range of insight; there is very little research
investigating delusionality in SAD or BDD. In some Eastern
cultures, BDD is conceived of as a subtype of SAD; however, the
relationship between culture, SAD and BDD remains poorly
understood.
Fang A, Hofmann SG. Relationship between social anxiety disorder and body
dysmorphic disorder. Clin Psychol Rev. 2010;30(8):1040-8.
EXPLANATION

QUESTION 18
Which of the following statements most accurately describes the
benefits of selective serotonin reuptake inhibitors (SSRIs) in the
treatment of posttraumatic stress disorder (PTSD)? SSRIs have
been shown to:
A. ameliorate core PTSD symptoms.
B. treat primarily the comorbid psychiatric disorders.
C. improve primarily hyperarousal symptoms.
D. act only to augment psychotherapy in PTSD.
Class responses


QUESTION 18
Final answer?

been shown to:
A. ameliorate core PTSD symptoms. (6)
B. treat primarily the comorbid psychiatric disorders. (1)
C. improve primarily hyperarousal symptoms. (1)

ANSWER 18
Explanation

been shown to:
A. ameliorate core PTSD symptoms.
B. treat primarily the comorbid psychiatric disorders.
C. improve primarily hyperarousal symptoms.

In randomized controlled studies, SSRIs have repeatedly
demonstrated efficacy in treating PTSD by reducing the core
symptoms of PTSD, reducing symptoms due to comorbid disorders
such as depression and memory problems, and increasing quality
of life. SSRIs are considered the first line medication treatment for
PTSD.
Davis, LL et al. Long-term pharmacotherapy for post-traumatic stress disorder.
CNS Drugs. 2006;20(6):465-76.
EXPLANATION

QUESTION 19
A genetic susceptibility for obsessive compulsive disorder (OCD) is
suggested by evidence that there is a familial link with:
A. panic disorder.
B. tic disorder.
C. bipolar disorder.
D. attention-deficit/hyperactivity disorder (ADHD).
E. substance use disorders.
Class responses


QUESTION 19
Final answer?

A. panic disorder.
B. tic disorder. (8)

ANSWER 19
Explanation

A. panic disorder.
B. tic disorder.

“Epidemiologically, OCD occurs more frequently than expected in
TS relatives than in the general population, even if the TS
probands do not have OCD.5 Starting from OCD probands mostly
free from tic disorders, evidence also suggests that there is an
increase in tic disorders in OCD relatives. Hence it is likely that
OCD and TS share genetic substrates.”
Grados MA. The genetics of obsessive-compulsive disorder and Tourette
syndrome: an epidemiological and pathway-based approach for gene discovery. J
Am Acad Child Adolesc Psychiatry. 2010;49(8):810-9, 819.e1-2.
EXPLANATION

QUESTION 20
Buspirone is thought to exert its anxiolytic effects in part through
its actions at which of the following receptor types?
A. GABA, Type A
B. Serotonin, 5HT-1A
C. Serotonin, 5HT-2A
D. Histamine, Type 1
E. Alpha-adrenergic, Type 1
Class responses
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QUESTION 20
Need a hint?

A. GABA, Type A
B. Serotonin, 5HT-1A (5)
C. Serotonin, 5HT-2A (3)

Loane C, Politis M. Buspirone: what is it all about?. Brain Res.
2012;1461:111-8.
Celada P, Bortolozzi A, Artigas F. Serotonin 5-HT1A receptors as
targets for agents to treat psychiatric disorders: rationale and
current status of research. CNS Drugs. 2013;27(9):703-16.
NEED A HINT?
Final answer?


ANSWER 20
A. GABA, Type A
B. Serotonin, 5HT-1A
C. Serotonin, 5HT-2A

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