Anxiety Disorders: Maudsley
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Questions and Answers

Benzodiazepines should be used with caution in the treatment of post-traumatic stress disorder (PTSD).

True

SSRIs should initially be prescribed at the normal starting dose for treating Generalised Anxiety Disorder (GAD).

False

The optimal duration of treatment for Generalised Anxiety Disorder (GAD) has been clearly determined.

False

Clonazepam has been shown to augment responses in treatment without increasing the overall magnitude of response.

<p>True</p> Signup and view all the answers

The initial response to treatment for obsessive-compulsive disorder (OCD) emerges faster than in depression.

<p>False</p> Signup and view all the answers

SSRIs, when used for Body Dysmorphic Disorder (BDD), are effective only when used alone without any combination therapy.

<p>False</p> Signup and view all the answers

Lower starting doses are also recommended for treating post-traumatic stress disorder (PTSD).

<p>True</p> Signup and view all the answers

Women may respond better to SSRIs than men in treating anxiety disorders.

<p>True</p> Signup and view all the answers

Social phobia patients treated with SSRIs do not require any monitoring for increased anxiety or suicidal ideation.

<p>False</p> Signup and view all the answers

Fluoxetine is indicated for all anxiety disorders without any dosage adjustment.

<p>False</p> Signup and view all the answers

Anxiety spectrum disorders can only occur in isolation and are never co-morbid with other psychiatric disorders.

<p>False</p> Signup and view all the answers

High initial doses of SSRIs are generally well tolerated by individuals with anxiety disorders.

<p>False</p> Signup and view all the answers

Benzodiazepines are recommended for long-term treatment of severe anxiety without any caution.

<p>False</p> Signup and view all the answers

NICE advises that benzodiazepines should be utilized to treat panic disorder.

<p>False</p> Signup and view all the answers

Patients with substance misuse issues should be treated with benzodiazepines without hesitation.

<p>False</p> Signup and view all the answers

Benzodiazepines can provide rapid symptomatic relief from acute anxiety states.

<p>True</p> Signup and view all the answers

A small number of patients with severely disabling anxiety may benefit from long-term treatment with benzodiazepines.

<p>True</p> Signup and view all the answers

Caffeine is known to be a drug that can induce anxiety disorders.

<p>True</p> Signup and view all the answers

Benzodiazepines are commonly under-prescribed for anxiety and depression in the United States.

<p>False</p> Signup and view all the answers

Alprazolam is widely used for treating panic disorder in some countries.

<p>True</p> Signup and view all the answers

Which of the following drugs is recommended as a first-line treatment for Generalised Anxiety Disorder?

<p>Sertraline</p> Signup and view all the answers

Benzodiazepines are recommended for long-term treatment of anxiety disorders.

<p>False</p> Signup and view all the answers

What is the dosage range for Pregabalin in the treatment of Generalised Anxiety Disorder?

<p>150-600mg/day in divided doses</p> Signup and view all the answers

The drug _____ is known for its delayed onset of action and may take up to 6 weeks to show efficacy comparable to benzodiazepines.

<p>Buspirone</p> Signup and view all the answers

Match the following drugs to their comments:

<p>Agomelatine = Prevents relapse over a 6-month period Propranolol = Useful for somatic symptoms, particularly tachycardia Clomipramine = Initiate at 10mg/day and increase gradually Chamomile = RCTs show mixed results</p> Signup and view all the answers

Which of the following statements is true regarding SSRIs?

<p>SSRIs may initially worsen symptoms; a lower starting dose is suggested.</p> Signup and view all the answers

Quetiapine is recommended as adjunctive therapy to SSRIs or SNRIs in treatment resistance.

<p>False</p> Signup and view all the answers

What is the maximum dosage for Phenelzine in the treatment of Generalised Anxiety Disorder?

<p>90mg/day in divided doses</p> Signup and view all the answers

_____ is significantly misused and can cause withdrawal symptoms when stopped.

<p>Pregabalin</p> Signup and view all the answers

Which experimental treatment for anxiety disorders has shown positive results in one RCT?

<p>Gingko biloba</p> Signup and view all the answers

What is the recommended maximum initial dose of Venlafaxine for treating panic disorder?

<p>37.5mg</p> Signup and view all the answers

Benzodiazepines are recommended as a first-line treatment for panic disorder.

<p>False</p> Signup and view all the answers

What is one potential effect of starting SSRIs in panic disorder patients?

<p>Initial exacerbation of panic symptoms</p> Signup and view all the answers

The drug _________ is suggested to improve anxiety but has limited data on its effect on panic symptoms.

<p>Mirtazapine</p> Signup and view all the answers

Match the following drugs with their comments:

<p>Clomipramine = Start with a low dose and increase according to response. D-cycloserine = Accelerates treatment response to CBT. Gabapentin = No difference between gabapentin and placebo. Hydrocortisone = Prevents development of PTSD in acute treatment.</p> Signup and view all the answers

Which drug is included in the second-line treatment options for panic disorder?

<p>SSRIs</p> Signup and view all the answers

The efficacy of phenelzine is supported by long-term studies.

<p>False</p> Signup and view all the answers

What is the usual dosage range for Clomipramine in treating panic disorder?

<p>25-250mg/day</p> Signup and view all the answers

The drug _________ has shown significant improvement in more severely ill patients according to one RCT.

<p>Gabapentin</p> Signup and view all the answers

Which of the following treatments is not typically recommended for first-line use in panic disorder?

<p>Benzodiazepines</p> Signup and view all the answers

Which of the following SSRIs is preferred for first-line treatment of PTSD?

<p>Paroxetine</p> Signup and view all the answers

Antipsychotics are effective for avoidance and hyperarousal symptoms of PTSD.

<p>False</p> Signup and view all the answers

What is the recommended initial dosage range for Prazosin in treating PTSD-related nightmares?

<p>1-15 mg nocte</p> Signup and view all the answers

The most effective drug in a network meta-analysis for PTSD is __________.

<p>Phenelzine</p> Signup and view all the answers

Match the following drugs with their respective usage:

<p>Olanzapine = 5-20mg Mirtazapine = 15-45mg/day Venlafaxine = 37.5-300mg Risperidone = 0.5-6mg</p> Signup and view all the answers

Which drug is recommended as the second most effective in treating PTSD according to a network meta-analysis?

<p>Mirtazapine</p> Signup and view all the answers

SSRIs should be administered at maximum licensed doses for effective PTSD management.

<p>True</p> Signup and view all the answers

What is the maximum dosage for Quetiapine in PTSD treatment?

<p>800 mg</p> Signup and view all the answers

Duloxetine is an __________ treatment for PTSD with positive results in small studies.

<p>experimental</p> Signup and view all the answers

Which drug should be initiated at 30mg for one week in PTSD treatment?

<p>Duloxetine</p> Signup and view all the answers

What is the maximum dosage for Clomipramine in the treatment of obsessive compulsive disorder?

<p>250mg</p> Signup and view all the answers

Adding an antipsychotic to an SSRI is considered first-line treatment for OCD.

<p>False</p> Signup and view all the answers

Name one SSRI that can be used as first-line treatment for obsessive compulsive disorder.

<p>Any SSRI</p> Signup and view all the answers

_________ has shown good evidence for treating OCD when added to SSRIs.

<p>Memantine</p> Signup and view all the answers

Match the following drugs to their comments on treatment use:

<p>Venlafaxine = Up to 375mg for OCD Granisetron = 1mg with fluvoxamine Citalopram = 40mg with clomipramine Topiramate = Up to 400mg added to SSRI</p> Signup and view all the answers

Which of the following is an experimental treatment for OCD?

<p>Escitalopram 25-50mg</p> Signup and view all the answers

Topiramate is well tolerated and effective for both compulsions and obsessions in OCD treatment.

<p>False</p> Signup and view all the answers

What is the recommended dosage of acetylcysteine to be added to SSRI or clomipramine?

<p>Up to 2400mg/day</p> Signup and view all the answers

The combination of Granisetron with fluvoxamine shows some evidence for ________.

<p>OCD treatment</p> Signup and view all the answers

What is a common side effect of adding acetylcysteine to OCD treatment?

<p>Gastrointestinal adverse effects</p> Signup and view all the answers

What is the suggested outcome of adding Pregabalin to sertraline?

<p>One small positive RCT</p> Signup and view all the answers

Riluzole added to existing drug treatment has yielded consistent positive results in trials.

<p>False</p> Signup and view all the answers

What is the dosage range for once weekly morphine added to existing drug treatment?

<p>15-45mg</p> Signup and view all the answers

The anti-androgen Triptorelin is administered at a dosage of ____ mg IM every 4 weeks.

<p>3.75</p> Signup and view all the answers

Match the drugs to their study outcome:

<p>Pregabalin = One small positive RCT Riluzole = Variable results in early trials Clomipramine IV = Quicker onset of action suggested Once weekly morphine = Transient positive effects in a small study</p> Signup and view all the answers

What is the usual dosage range for Venlafaxine modified release in treating social phobia?

<p>75-225mg/day</p> Signup and view all the answers

Moclobemide has a UK license for Social Phobia.

<p>True</p> Signup and view all the answers

Which antipsychotic has the most evidence for treating social phobia?

<p>Olanzapine</p> Signup and view all the answers

_________ is the first-line drug treatment option for social anxiety disorder.

<p>SSRIs</p> Signup and view all the answers

Match the following drugs with their recommended doses:

<p>Clonazepam = 0.3-6 mg/day Pregabalin = 150-600mg/day Atenolol = 25-100mg/day Phenelzine = 15-90mg/day</p> Signup and view all the answers

Which of the following is a second-line drug treatment for social phobia?

<p>Gabapentin</p> Signup and view all the answers

The maximum dosage of Phenelzine for social phobia is 90mg/day.

<p>True</p> Signup and view all the answers

What emerging data supports which SSRI for social anxiety treatment?

<p>Fluvoxamine and Citalopram</p> Signup and view all the answers

The experimental treatment __________ has shown positive results in one RCT for anxiety disorders.

<p>Ketamine</p> Signup and view all the answers

Which dosage range is recommended for Gabapentin in treating social phobia?

<p>900-3600mg/day</p> Signup and view all the answers

Study Notes

Anxiety Spectrum Disorders Overview

  • Anxiety disorders can exist alone or co-occur with other mental health conditions, especially depression.
  • May arise from physical health issues (e.g., thyrotoxicosis) or be drug-induced (e.g., caffeine).
  • Often chronic, with treatment yielding only partial success.
  • Individuals may experience heightened sensitivity to adverse medication effects.

Benzodiazepines

  • Provide quick relief from acute anxiety symptoms.
  • Recommended only for severe, disabling anxiety conditions due to risk of dependence.
  • Should be used at the lowest effective dose and for a maximum of 4 weeks while initiating other long-term treatments.
  • Over-prescription is common, especially in the U.S., for both anxiety and depression.
  • Not recommended for panic disorder by NICE guidelines; alprazolam is frequently used in other countries for this purpose.
  • Extreme caution is necessary in patients with PTSD.

SSRIs and SNRIs in Generalized Anxiety Disorder (GAD)

  • Initiate SSRIs at half the normal starting dose, increasing to full dosage as tolerated.
  • Initial increase in anxiety may occur; benefits typically seen within 6 weeks and continue to grow.
  • Minimum treatment duration should be one year to effectively prevent major depression.
  • Network meta-analysis indicates fluoxetine is the most effective SSRI, while sertraline is the most tolerated.
  • Clomipramine, citalopram, and sertraline at lower doses balance efficacy with side effects; higher paroxetine doses may be necessary.
  • Women may have a better response to SSRIs than men.

Treatment for Panic Disorder

  • Starting dose and titration should follow GAD guidelines.
  • Efficacy of SSRIs increases with higher doses for anxiety disorders.
  • Treatment duration should last at least 8 months, with evidence supporting at least 3 years of benefit from continuous use.
  • Less than half maintain wellness after stopping medication.

Post-Traumatic Stress Disorder (PTSD)

  • Lower starting doses of SSRIs are required; higher doses (e.g., fluoxetine 60mg) may be needed for maximum effect.
  • Initial response time ranges from 8 to 12 weeks; treatment should continue for at least 6 months.

Obsessive-Compulsive Disorder (OCD)

  • Higher SSRI doses licensed for OCD versus depression; lower doses can be effective for maintenance.
  • Initial response typically takes 10 to 12 weeks, requiring dose increases for optimal results.
  • Treatment should continue for at least one year, with reduced relapse rates in prolonged therapy.
  • Commonly chronic condition, often with fluctuating symptom severity; second-line treatments include risperidone or aripiprazole.

Body Dysmorphic Disorder (BDD) and Social Anxiety Disorder

  • Initial treatment for BDD is CBT; SSRIs may be added for moderate to severe symptoms.
  • Buspirone can enhance SSRI effectiveness, although no RCT exists.
  • Starting doses of SSRIs for social phobia are well-tolerated; benefits often appear within 8 weeks.
  • NICE recommends CBT as the first-line treatment for social anxiety.
  • Continuous monitoring for akathisia, increased anxiety, and suicidal ideation is essential for all patients on SSRIs, especially vulnerable individuals.

Crisis Management

  • Benzodiazepines are typically recommended for short-term use (2-4 weeks) to manage anxiety but concerns about risks exist.

First-line Drug Treatment

  • SSRIs, such as fluoxetine and sertraline, are favored; may worsen symptoms initially; start with a lower dose.
  • SNRIs may also exacerbate symptoms initially; lower starting doses are suggested.
  • Pregabalin (150-600mg/day) can show response in the first week; however, it has potential for misuse and significant withdrawal symptoms.

Second-line Drug Treatment

  • Agomelatine (10-50mg/day) has shown efficacy in preventing relapse over six months, though it is less well tolerated compared to first-line options.

Betablockers

  • Propranolol (40-120mg/day) can relieve somatic symptoms like tachycardia; start at 40mg and titrate as needed.
  • Buspirone (15-60mg/day) has a delayed onset, taking up to six weeks to match benzodiazepine efficacy.
  • Hydroxyzine (50-100mg/day) effectiveness is uncertain; may act as a sedative or anxiolytic.
  • Quetiapine (50-300mg, MR) is suggested as monotherapy; not effective as an adjunct treatment for resistant cases.

Tricyclic Antidepressants

  • Clomipramine (50-250mg/day) should start at 10mg/day with gradual increases.
  • Imipramine (75-200mg/day) begins at 25mg every four days; after reaching 100mg, increases should be in 50mg increments.

MAOI

  • Phenelzine (45-90mg/day) is indicated for mixed anxiety and depression; patients must avoid tyramine-rich foods.
  • Mirtazapine (15-30mg nocte) is also specifically used for anxiety treatment.

Experimental Treatments

  • Chamomile (220-1500mg/day) has mixed results in two RCTs; one positive, one negative.
  • Ginkgo biloba (240-480mg/day) has shown positive efficacy in one RCT.
  • Lavender oil preparation (80-160mg/day) demonstrated effectiveness in one positive RCT.

Crisis Management

  • Benzodiazepines provide rapid relief of panic symptoms but have a quick return of symptoms upon withdrawal; not recommended by NICE.
  • Cochrane review presents a lukewarm endorsement for benzodiazepines.

First-Line Drug Treatment

  • SSRIs (up to maximum licensed dose):
    • Therapeutic effects may be delayed; initial worsening of panic symptoms can occur.
    • Supported by Cochrane evidence.
  • Venlafaxine XR (75-225 mg):
    • Begin treatment at 37.5 mg for the first week.

Second-Line Treatment

  • Mirtazapine (15-60 mg/day):
    • Meta-analysis indicates limited effectiveness for panic symptoms; more effective for associated anxiety.
  • Moclobemide (300-600 mg/day):
    • Evidenced in fixed-dose study (450 mg) and flexible-dose study.
  • MAOIs:
    • Phenelzine (10-60 mg/day):
      • Reserved for treatment-resistant cases; lacks long-term study support due to poor tolerability.

Tricyclic Antidepressants

  • Clomipramine (25-250 mg/day):
    • Start with a low dose, adjust based on response and tolerability.
  • Imipramine (25-300 mg/day):
    • Another TCA option.
  • Lofepramine (70-140 mg/day in divided doses):
    • Used for panic disorder management.

Experimental Treatments

  • D-cycloserine (50 mg/day):
    • Randomized controlled trial (RCT) shows it can accelerate CBT response but benefits diminish at follow-up.
  • Gabapentin (600-3600 mg/day):
    • RCT demonstrated no significant difference from placebo, but notable improvement in severe cases.
  • Inositol (12 g/day):
    • Positive findings in one pilot controlled trial; comparable to fluvoxamine in another study; well tolerated.
  • Levetiracetam (250 mg twice daily):
    • Generally well-tolerated in studies.
  • Pindolol (7.5 mg/day):
    • Suggestive efficacy in augmenting fluoxetine for treatment-resistant panic disorder based on small double-blind controlled trial.
  • Valproate (500-2250 mg/day):
    • Positive results from two small open studies.
  • Hydrocortisone:
    • Effective for acute treatment to prevent PTSD development.

First-line Drug Treatment

  • Psychological approaches are prioritized over drugs for PTSD treatment.
  • SSRIs are the preferred first-line treatment, with specific recommendations for Paroxetine, Sertraline, and Fluoxetine at maximum licensed doses.
  • Venlafaxine modified release (37.5mg-300mg) is also recommended by NICE as a first-line treatment.

Second-line Treatment

  • Second-line treatments have less tolerability or weaker evidence and are not prioritized:

Antipsychotics

  • Olanzapine dosage ranges from 5-20mg.
  • Risperidone (0.5-6mg) is noted for its effectiveness on intrusive symptoms like flashbacks and nightmares but not on avoidance or hyperarousal symptoms. It is specifically mentioned by NICE.
  • Quetiapine can be administered at doses of 50-800mg.

Mirtazapine

  • Recommended dosage is 15-45mg/day, noted as the second most effective drug in a network meta-analysis.

MAOI

  • Phenelzine (15-75mg/day) is highly recommended by NICE and considered the most effective drug in network meta-analysis.

Prazosin

  • Dosage for Prazosin is 2-15mg at night, targeting nightmares and sleep disturbances. Starts at 1mg nocte, with gradual dose increase to minimize hypotension risk, supported by a systematic review.

Tricyclic Antidepressants

  • Amitriptyline (50-300mg/day) is recommended by NICE. It’s important to start at low doses and adjust based on tolerance. Best supporting evidence is for Desipramine, though it is not widely available.
  • Other options include Imipramine (50-300mg/day) and V Ketamine.

Experimental Treatments

  • Duloxetine (60-120mg) shows potential efficacy based on two small studies; initiate at 30mg for the first week.
  • Lamotrigine is investigated in a small double-blind study involving 15 patients.
  • Phenytoin should maintain plasma concentrations between 10-20ng/ml, evaluated in an open-label study with 12 patients.
  • Valproate (up to 2.5g) is likely ineffective for PTSD.

First-line Drug Treatment

  • SSRIs (Selective Serotonin Reuptake Inhibitors) are preferred; maximum licensed doses are utilized.
  • Alternative SSRIs may be employed if the first choice is intolerable or ineffective.
  • Clomipramine is considered as a secondary option, with a recommended maximum of 250mg due to tolerability concerns.

Second-line Drug Treatment

  • Antipsychotics can be added to SSRIs, with aripiprazole and risperidone being the most supported options; haloperidol has some evidence as well.
  • A combination of citalopram (40mg) and clomipramine (150mg) is backed by a small study, though ECG monitoring is necessary.
  • Acetylcysteine, up to 2400mg/day, may provide benefits when added to SSRIs or clomipramine despite some gastrointestinal side effects and mixed study results.
  • Lamotrigine, at 100mg, should be gradually titrated; it has potential to worsen OCD symptoms in some cases.
  • Topiramate, up to 400mg added to SSRIs, may help with compulsions but has shown ineffectiveness against obsessions and poor tolerability.

Experimental Treatments

  • High-dose SSRIs such as escitalopram (25-50mg) and sertraline (250-400mg) require gradual titration and ECG monitoring.
  • Memantine has strong evidence for its efficacy when used at 20mg/day in conjunction with SSRIs.

NSAIDs

  • Celecoxib, at a dose of 400mg/day, shows some supportive evidence for OCD treatment.
  • Amantadine at 200mg/day has shown positive results in a randomized controlled trial.

SNRIs

  • Venlafaxine can be prescribed up to 375mg for OCD treatment.
  • Duloxetine is prescribed at 60mg.
  • Mirtazapine has been tested in a small trial with a dosage between 30-60mg.

5HT3 Antagonists

  • Granisetron (1mg) combined with fluvoxamine (200mg) has some support, while ondansetron may prove more effective in certain scenarios.
  • Ondansetron (4mg) alongside fluoxetine (20mg) is also considered a treatment option.

Drug Outcomes Summary

  • Pregabalin (75-225mg/day) added to sertraline shows positive results in one small randomized controlled trial (RCT).
  • Riluzole (50mg twice daily) combined with other treatments produced inconsistent outcomes in early studies.
  • Anti-androgen treatment (Triptorelin 3.75mg IM) every four weeks has been assessed in an open-label study involving six men, generating preliminary insights.
  • Intravenous treatments:
    • Clomipramine IV proposed quicker action compared to oral forms; one study indicates efficacy after failure with oral clomipramine.
    • Ketamine IV is in development, showing a growing evidence base for effectiveness.
  • Once weekly morphine (15-45mg) added to existing treatment has shown transient positive effects in a small study with 23 treatment-resistant patients.

First-Line Drug Treatment

  • SSRIs: Effective treatment for Social Anxiety Disorder, prescribed up to the maximum licensed dose.
  • If initial SSRI is ineffective, an alternative SSRI should be considered.
  • Fluvoxamine and Citalopram: Supported by meta-analyses for effectiveness.
  • Vilazodone: Emerging data suggesting potential effectiveness.
  • Venlafaxine (modified release): Daily dosage between 75-225mg.

Second-Line Drug Treatment

  • Olanzapine: Antipsychotic prescribed at 5-20mg; evidence suggests it is the most effective among antipsychotics.
  • Atenolol: Dosed at 25-100mg/day; specifically reduces autonomic symptoms during performance situations.
  • Benzodiazepines:
    • Clonazepam: Daily dosage ranges from 0.3 to 6mg.
    • Combination of Sertraline and Clonazepam may improve outcomes, with clonazepam up to 3mg/day.
    • Benzodiazepines are useful on a PRN basis; clonazepam shows significant evidence for effectiveness.
    • Transitioning from an SSRI to Venlafaxine shows no notable improvement compared to adding clonazepam to an SSRI.
  • Gabapentin: Prescribed between 900-3600mg/day.
  • Levetiracetam: Daily dosage ranges from 300-3000mg in divided doses.

Experimental Treatments

  • Moclobemide: Initiate at 300mg/day, can increase to 600mg/day; UK licensed for Social Phobia and recommended by NICE.
  • Phenelzine: Dosed at 15-90mg/day; requires strict avoidance of tyramine-rich foods.
  • Pregabalin: Effective at dosages of 150-600mg/day, with 600mg/day showing superiority over placebo.
  • Ketamine: Administered at 0.5mg/kg intravenously; supported by one robust randomized controlled trial.
  • Topiramate: Daily dosage between 25-400mg; early studies suggest efficacy but report poor tolerability.
  • Valproate: Effective in small studies, with a dosing range of 500-2500mg/day.

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This quiz explores the appropriate use of benzodiazepines in post-traumatic stress disorder and the initial dosing guidelines for SSRIs and SNRIs in treating generalized anxiety disorder. Participants will learn about potential side effects, including initial worsening of symptoms, as well as the timeline for observing benefits from treatment. Examine the nuances of medication management in mental health.

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