MD notes

In Short: Clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders (2014)

May 11, 2024•5,093 words

Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders (2014)

Though they haven't been updated in a long time, the 2014 guidelines published in BMC are still the only ones I know of that are Canada specific. As the guideline makes much of the content difficult to read by stowing it in tables, I've made this short version that is as true as possible to the original. Drug treatments had tables with clear recommendations, but psychotherapies did not, so I have made a best effort to distil that content down while remaining true to the original. If in doubt, go back to the primary text linked above.

Suggested Screening Questions

General Screening Questions

During the past two weeks how much have you been bothered by the following problems?

  • Feeling nervous, anxious, frightened, worried, or on edge
  • Feeling panic or being frightened
  • Avoiding situations that make you anxious

Specific Screening Questions

Here's the cleaned-up text with a uniform formatting style and without citations:

Panic Disorder

  • Do you have sudden episodes, spells, or attacks of intense fear or discomfort that are unexpected or out of the blue?

If you answered "YES," then continue:

  • Have you had more than one of these attacks?
  • Does the worst part of these attacks usually peak within several minutes?
  • Have you ever had one of these attacks and spent the next month or more living in fear of having another attack or worrying about the consequences of the attack?

Social Anxiety Disorder

  • Does fear of embarrassment cause you to avoid doing things or speaking to people?
  • Do you avoid activities in which you are the center of attention?
  • Is being embarrassed or looking stupid among your worst fears?

Generalized Anxiety Disorder

  • During the past 4 weeks, have you been bothered by feeling worried, tense, or anxious most of the time?
  • Are you frequently tense, irritable, and having trouble sleeping?

Obsessive-Compulsive Disorder

Obsessions:

  • Are you bothered by repeated and unwanted thoughts of any of the following types:
    • Thoughts of hurting someone else
    • Sexual thoughts
    • Excessive concern about contamination, germs, or disease
    • Preoccupation with doubts ("what if" questions) or an inability to make decisions
    • Mental rituals (e.g., counting, praying, repeating)
    • Other unwanted intrusive thoughts

If you answered "YES" to any of the above... Do you have trouble resisting these thoughts, images, or impulses when they come into your mind?

Compulsions:

  • Do you feel driven to perform certain actions or habits over and over again, or in a certain way, or until it feels just right, such as:
    • Washing, cleaning
    • Checking (e.g., doors, locks, appliances)
    • Ordering/arranging
    • Repeating (e.g., counting, touching, praying)
    • Hoarding/collecting/saving

If you answered "YES" to any of the above... Do you have trouble resisting the urge to do these things?

Post-Traumatic Stress Disorder – MACSCREEN

  • Have you experienced or seen a life-threatening or traumatic event such as a rape, accident, someone badly hurt or killed, assault, natural or man-made disaster, war, or torture?

If you answered "YES," then continue:

  • Do you re-experience the event in disturbing (upsetting) ways such as dreams, intrusive memories, flashbacks, or physical reactions to situations that remind you of the event?

Risk Factors

Certain risk factors have been associated with anxiety and related disorders and should increase the clinician’s index of suspicion:

  • Family history of anxiety
  • Personal history of anxiety or mood disorder
  • Childhood stressful life events or trauma
  • Being female
  • Chronic medical illness
  • Behavioral inhibition

Associated Medical Conditions

Patients with anxiety disorders have a higher prevalence of hypertension and other cardiovascular conditions, gastrointestinal disease, arthritis, thyroid disease, respiratory disease, migraine headaches, and allergic conditions compared to those without anxiety disorders.

Key Features of Each Disorder

Panic Disorder

  • Recurrent unexpected panic attacks, in the absence of triggers.
  • Persistent concern about additional panic attacks and/or maladaptive change in behavior related to the attacks.

Agoraphobia

  • Marked, unreasonable fear or anxiety about a situation.
  • Active avoidance of feared situation due to thoughts that escape might be difficult or help unavailable if panic-like symptoms occur.

Specific Phobia

  • Marked, unreasonable fear or anxiety about a specific object or situation, which is actively avoided (e.g., flying, heights, animals, receiving an injection, seeing blood).

Social Anxiety Disorder (SAD)

  • Marked, excessive or unrealistic fear or anxiety about social situations in which there is possible exposure to scrutiny by others.
  • Active avoidance of feared situation.

Generalized Anxiety Disorder (GAD)

  • Excessive, difficult to control anxiety and worry (apprehensive expectation) about multiple events or activities (e.g., school/work difficulties).
  • Accompanied by symptoms such as restlessness/feeling on edge or muscle tension.

Obsessive-Compulsive Disorder (OCD)

  • Obsessions: Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, causing marked anxiety or distress.
  • Compulsions: Repetitive behaviors (e.g., hand washing) or mental acts (e.g., counting) that the individual feels driven to perform to reduce the anxiety generated by the obsessions.

Posttraumatic Stress Disorder (PTSD)

  • Exposure to actual or threatened death, serious injury, or sexual violation.
  • Intrusion symptoms (e.g., distressing memories or dreams, flashbacks, intense distress) and avoidance of stimuli associated with the event.
  • Negative alterations in cognitions and mood (e.g., negative beliefs and emotions, detachment), as well as marked alterations in arousal and reactivity (e.g., irritable behavior, hypervigilance).

DSM-5 Criteria

Panic Attacks

An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and includes ≥4 of the following symptoms:

(1) Palpitations, pounding heart, or accelerated heart rate

(2) Sweating

(3) Trembling or shaking

(4) Sensations of shortness of breath or smothering

(5) Feelings of choking

(6) Chest pain or discomfort

(7) Nausea or abdominal distress

(8) Feeling dizzy, unsteady, light-headed, or faint

(9) Chills or heat sensations

(10) Paresthesias (numbness or tingling sensations)

(11) Derealization (feelings of unreality) or depersonalization (being detached from oneself)

(12) Fear of losing control or going crazy

(13) Fear of dying

Panic Specifier

Panic attacks frequently occur in other psychiatric disorders (e.g., MDD, PTSD), and medical conditions (e.g., cardiac, respiratory), and the DSM-5 has identified panic attacks as a specifier to be used in the absence of a diagnosable panic disorder .

Panic Disorder

The person has experienced both of the following:

  1. Recurrent unexpected panic attacks
  2. ≥1 of the attacks followed by ≥1 month of 1 or both of the following:
  3. Persistent concern or worry about additional panic attacks or their consequences
  4. Significant maladaptive change in behavior related to the attacks

Agoraphobia

  • Marked fear or anxiety about two or more of the following five groups of situations:

    1. Public transportation (e.g., traveling in automobiles, buses, trains, ships, or planes).
    2. Open spaces (e.g., parking lots, marketplaces, or bridges).
    3. Being in shops, theaters, or cinemas.
    4. Standing in line or being in a crowd.
    5. Being outside of the home alone in other situations.

  • The individual fears or avoids these situations due to thoughts that escape might be difficult or help might not be available in the event of panic-like symptoms.

  • The agoraphobic situations almost always provoke fear or anxiety.

  • The situations are actively avoided, require the presence of a companion, or are endured with marked fear or anxiety.

  • The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situation.

  • The fear, anxiety, or avoidance is persistent, typically lasting six months or longer.

  • The fear, anxiety, and avoidance cause clinically significant distress or functional impairment.

Specific Phobia

  • Marked fear or anxiety about a specific object or situation (e.g., flying, seeing blood).

  • The phobic object or situation almost always provokes immediate fear or anxiety and is actively avoided or endured with marked fear or anxiety.

  • The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation.

  • The fear, anxiety, or avoidance is persistent, typically lasting six months or longer.

  • There is marked distress or functional impairment.

Specific Phobia Specifiers

  • Animal

    • Spiders
    • Insects
    • Dogs

  • Natural environment

    • Heights
    • Storms
    • Water

  • Blood-injection-injury

    • Needles
    • Invasive medical procedures

  • Situational

    • Airplanes
    • Elevators
    • Enclosed spaces

  • Other

    • Choking or vomiting. (In children, loud sounds or costumed characters.)

Specific Phobia Treatments

Exposure-based techniques, including virtual exposure, are highly effective, and are the foundation of treatment for specific phobias. Pharmacotherapy is generally unproven, and thus not a recommended treatment for most cases.

  • Exposure-based treatments: All specific phobias
  • Virtual reality exposurs: Heights, flying, spiders, claustrophobia
  • Computer-based self-help programs: Spiders, flying, small animals
  • Applied muscle tension (exposure combined with muscle tension exercises): Blood-injection-injury type
  • Cognitive therapy and exposure: Dental, flying

Social Anxiety Disorder

  • Marked fear or anxiety about social situations in which the person may be exposed to scrutiny by others.

  • Fear that actions or showing anxiety symptoms will cause negative evaluation (e.g., embarrassment, humiliation) or offend others.

  • The social situation:

    • Almost always provokes fear or anxiety.
    • Is actively avoided or endured with marked fear or anxiety.

  • The fear, anxiety, or avoidance:

    • Is out of proportion to the actual threat posed by the social situation.
    • Is persistent, typically lasting six months or longer.
    • Causes significant distress or functional impairment.

  • If another medical condition is present (e.g., stuttering, obesity), the disturbance is unrelated or out of proportion to it.

  • Specify “performance only” if the fear is restricted to speaking or performing in public.

Treatments

Psychotherapy For Social Anxiety Disorder

  • Psychological Treatment for Social Anxiety Disorder (SAD)

    • Cognitive Behavioral Therapy (CBT) is the gold-standard nonpharmacological treatment for SAD.
    • CBT involves restructuring maladaptive thoughts and exposure therapy.
    • Numerous Randomized Controlled Trials (RCTs) support the efficacy of CBT compared to placebo or treatment-as-usual.
    • CBT can be administered in group or individual formats, with similar efficacy.
    • Exposure therapy alone has evidence supporting its effectiveness, but its efficacy compared to CBT alone is uncertain.

  • Variants of CBT

    • CBT with Virtual Reality Exposure (VRE) is effective and comparable to other exposure modalities.
    • Interpersonal CBT and Mindfulness-Based Therapy (MBT) show improvements in SAD symptoms, albeit less effective than traditional CBT.
    • Attentional Bias Training shows potential benefits, but data are conflicting.
    • Internet-based CBT (ICBT) has demonstrated efficacy in RCTs and may increase access to treatment.
    • The necessity of therapist involvement in ICBT remains uncertain.
    • ICBT is as effective as face-to-face CBT, with lower costs.

  • Combined Psychological and Pharmacological Treatments

    • Some studies show pharmacotherapy does not add to the benefits of CBT.
    • D-cycloserine enhances treatment outcomes when used during exposure exercises.
    • Combination treatment with psychodynamic group therapy and clonazepam may be superior to clonazepam alone.

  • Long-term Effects of Psychological Treatment

    • Benefits of CBT are maintained at follow-up visits and sustained improvement is reported at five years posttreatment.
    • Long-term benefits of psychotherapy appear more enduring than those of pharmacotherapy after treatment discontinuation.

Drug Treatments For Social Anxiety Disorder

  • First-line

    • Escitalopram
    • Fluvoxamine (IR and CR form)
    • Paroxetine (IR and CR form)
    • Pregabalin
    • Sertraline
    • Venlafaxine XR

  • Second-line

    • Alprazolam
    • Bromazepam
    • Citalopram
    • Clonazepam
    • Gabapentin
    • Phenelzine

  • Third-line

    • Atomoxetine
    • Bupropion SR
    • Clomipramine
    • Divalproex
    • Duloxetine
    • Fluoxetine
    • Mirtazapine
    • Moclobemide
    • Olanzapine
    • Selegiline
    • Tiagabine
    • Topiramate

  • Adjunctive Therapy

    • Third-line: Aripiprazole, Buspirone, Paroxetine, Risperidone

  • Not Recommended

    • Clonazepam
    • Pindolol

  • Not Recommended

    • Atenolol*
    • Buspirone
    • Imipramine
    • Levetiracetam
    • Propranolol*
    • Quetiapine

Generalized Anxiety Disorder

Diagnostic Criteria

  • Excessive anxiety and worry (apprehensive expectation) about a variety of events or activities (e.g., school/work performance).
  • Difficulty controlling the worry.
  • Excessive anxiety and worry are associated with three or more of the following symptoms (with at least some occurring more days than not for six months or longer):
    • Restlessness or feeling keyed-up or on edge.
    • Being easily fatigued.
    • Difficulty concentrating.
    • Irritability.
    • Muscle tension.
    • Sleep disturbance.
  • The disturbance causes clinically significant distress or functional impairment.

Therapy-Based Treatments:

  1. First-Line:
    • Cognitive Behavioral Therapy (C.B.T.)
    • Internet-based C.B.T.
    • Computer-based C.B.T.

Drug-Based Treatments:

  1. First-Line Pharmacotherapy:

    • Selective Serotonin Reuptake Inhibitors (S.S.R.I.s):
      • Escitalopram
      • Paroxetine
      • Sertraline
    • Serotonin and Norepinephrine Reuptake Inhibitors (S.N.R.I.s):
      • Duloxetine
      • Venlafaxine X.R.
    • Other Antidepressants:
      • Agomelatine
    • Anticonvulsants:
      • Pregabalin

  2. Second-Line Pharmacotherapy:

    • Bupropion X.L.
    • Buspirone
    • Hydroxyzine
    • Imipramine
    • Quetiapine X.R.
    • Vortioxetine
    • Benzodiazepines:
      • Alprazolam
      • Bromazepam
      • Diazepam
      • Lorazepam

  3. Third-Line and Adjunctive Therapies:

    • Consider reassessment of diagnosis
    • Consideration of comorbid conditions
    • Possible use of biological and alternative therapies
      • rTMS (repetitive Transcranial Magnetic Stimulation)
      • Herbal Preparations:
      • Silexan (Lavender oil)
      • Galphimia glauca extract
      • Passiflora (Passion flower)
      • Valerian
      • Physical Exercise:
      • Resistance training (weightlifting)
      • Aerobic exercise
      • Acupuncture
      • Mindfulness and Movement-Based Therapies:
      • Meditation
      • Yoga-based treatments

Obsessive Compulsive Disorder

Criteria for the Diagnosis of Obsessive-Compulsive Disorder:

  1. Presence of Obsessions, Compulsions, or Both:

    • Obsessions:
      • Recurrent and persistent thoughts, urges, or images experienced as intrusive and unwanted, causing marked anxiety or distress.
      • The individual attempts to ignore or suppress these thoughts, urges, or images, or to neutralize them with other thoughts or actions.
    • Compulsions:
      • Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rigid rules.
      • These behaviors or mental acts are aimed at preventing or reducing anxiety or a dreaded event or situation; however, they are not realistically connected with what they are designed to neutralize or are clearly excessive.

  2. Time and Impact:

    • The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or functional impairment.

  3. Specify: Insight into OCD Beliefs:

    • Good or Fair Insight: The individual believes the OCD beliefs are definitely or probably not true.
    • Poor Insight: The individual believes the OCD beliefs are probably true.
    • Absent Insight: The individual is completely convinced that the OCD beliefs are true.

  4. Specify: Tic-Related OCD:

    • Specify if the OCD is tic-related.

Psychotherapy for OCD:

  1. CBT that includes exposure response prevention (ERP).
  2. Internet-CBT
  3. ERP Bibliotherapy
  4. Maybe ACT
  5. Maybe Mindfulness

Adding drug treatment to therapy not recommended.

Drug Treatments for OCD:

Preference for psychotherapy should be given. If drug treatment preferred, there is evidence of additional benefit if psychotherapy can be added to medications.

First-Line:

  • Escitalopram
  • Fluoxetine
  • Fluvoxamine
  • Paroxetine
  • Sertraline

Second-Line:

  • Citalopram
  • Clomipramine
  • Mirtazapine
  • Venlafaxine X.R.

Third-Line:

  • I.V. Citalopram
  • I.V. Clomipramine
  • Duloxetine
  • Phenelzine
  • Tramadol
  • Tranylcypromine

Adjunctive Therapy:

  • First-Line:

    • Aripiprazole
    • Risperidone

  • Second-Line:

    • Memantine
    • Quetiapine
    • Topiramate

  • Third-Line:

    • Amisulpride
    • Celecoxib
    • Citalopram
    • Granisetron
    • Haloperidol
    • I.V. Ketamine
    • Mirtazapine
    • N-acetylcysteine
    • Olanzapine
    • Ondansetron
    • Pindolol
    • Pregabalin
    • Riluzole
    • Ziprasidone

Not Recommended:

  • Buspirone
  • Clonazepam
  • Lithium
  • Morphine
  • Clonidine
  • Desipramine

Other Treatments for OCD:

Biological Therapies:

  1. Repetitive Transcranial Magnetic Stimulation (rTMS)

    • Used as an adjunctive therapy for treatment-refractory Obsessive-Compulsive Disorder (O.C.D.)
    • Mixed results in efficacy; some trials show significant improvements, others do not

  2. Deep Brain Stimulation

    • Suggested to improve symptoms and functionality in patients with highly treatment-refractory O.C.D.

  3. Capsulotomy

    • Considered effective in reducing symptoms in patients with severe, treatment-refractory O.C.D.

  4. Cingulotomy

    • Similar to capsulotomy, used as a last resort for severe, treatment-refractory O.C.D.

Alternative Therapies:

  1. Meditation Therapies

    • Includes transcendental meditation and Kundalini yoga, compared with relaxation therapies

  2. Moderate-Intensity Aerobic Exercise

    • Suggested to help improve O.C.D. symptoms

  3. Herbal Therapies:

    • Milk Thistle (Silybum marianum L. Gaertn.)
    • Valerian Root (Valeriana officinalis L.)
    • St John’s Wort (Hypericum perforatum)
    • Noted for potential usefulness in O.C.D., but with caution due to poor standardization and variability in active ingredient concentrations

This list organizes the therapies into categories of biological and alternative treatments, highlighting their applications and limitations in the context of O.C.D. treatment.

PTSD

Criteria for the Diagnosis of Post-Traumatic Stress Disorder:

  1. Exposure to Trauma:

    • Directly experienced or witnessed the traumatic event.
    • Learned that the trauma occurred to a close family member or friend (note: the event must have been violent or accidental).
    • Experienced repeated exposure to aversive details of the trauma (e.g., first responders).

  2. Intrusion Symptoms (Presence of one or more):

    • Recurrent, involuntary, and intrusive distressing memories of the trauma.
    • Distressing dreams related to the trauma.
    • Dissociative reactions (e.g., flashbacks) where the individual feels or acts as if the traumatic events are recurring.
    • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
    • Marked physiological reactions to reminders of the traumatic event.

  3. Avoidance (Presence of one or more):

    • Avoidance of distressing memories, thoughts, or feelings closely associated with the traumatic event.
    • Avoidance of external reminders (e.g., people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings related to the trauma.

  4. Negative Alterations in Cognitions and Mood (Presence of two or more):

    • Inability to recall important aspects of the traumatic event (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
    • Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.
    • Persistent distorted blame of self or others about the cause or consequences of the traumatic event.
    • Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
    • Markedly diminished interest or participation in significant activities.
    • Feelings of detachment or estrangement from others.

  5. Alterations in Arousal and Reactivity (Presence of two or more):

    • Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
    • Reckless or self-destructive behavior.
    • Hypervigilance.
    • Exaggerated startle response.
    • Problems with concentration.
    • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

  6. Duration of Symptoms:

    • The disturbance lasts more than one month.

  7. Functional Significance:

    • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  8. Specification of Symptoms:

    • With dissociative symptoms (depersonalization or derealization).
    • With delayed expression (if the full criteria are not met until at least six months after the event).

Treatment

Psychotherapy

Highly Effective Therapies:

  1. Cognitive Behavioral Therapy (CBT)

    • Particularly effective in managing chronic PTSD.
    • Includes Exposure and Response Prevention (ERP) and Cognitive Processing Therapy (CPT).

  2. Eye Movement Desensitization and Reprocessing (EMDR)

    • Found to be as effective as CBT and often results in faster recovery.
    • Useful across various trauma types including sexual or interpersonal violence, civilian trauma, and military trauma.

  3. Prolonged Exposure (PE)

    • Extensively studied and highly effective, particularly imaginal and in vivo exposure.
    • Shows similar effectiveness to other active treatments like CBT and EMDR.

Specialized Therapies:

  1. Dialectical Behavior Therapy (DBT)

    • Initially developed for Borderline Personality Disorder (BPD) but also effective in reducing self-harm behaviors in PTSD patients.
    • Useful as a pretreatment to reduce self-harm behaviors, facilitating subsequent PTSD treatments.

  2. Internet-based CBT (ICBT)

    • Demonstrates effectiveness in improving PTSD symptoms, depression, anxiety, and disability.
    • Offers accessibility, particularly through remote or anonymous channels, beneficial for underserved areas.

Emerging and Adjunctive Treaties:

  1. Video-conference CBT and Virtual Reality Exposure (VRE) Therapy
    • Video-conference CBT has been found equally effective compared to face-to-face sessions.
    • VRE therapy shows utility in improving PTSD symptoms.

Medication

First-Line Treatments:

  • Fluoxetine
  • Paroxetine
  • Sertraline
  • Venlafaxine X.R.

Second-Line Treatments:

  • Fluvoxamine
  • Mirtazapine
  • Phenelzine

Third-Line Treatments:

  • Amitriptyline
  • Aripiprazole
  • Bupropion S.R.
  • Buspirone
  • Carbamazepine
  • Desipramine
  • Duloxetine
  • Escitalopram
  • Imipramine
  • Lamotrigine
  • Memantine
  • Moclobemide
  • Quetiapine
  • Reboxetine
  • Risperidone
  • Tianeptine
  • Topiramate
  • Trazodone

Adjunctive Therapy:

Second-Line Adjunctive Therapy:

  • Eszopiclone
  • Olanzapine
  • Risperidone

Third-Line Adjunctive Therapy:

  • Aripiprazole
  • Clonidine
  • Gabapentin
  • Levetiracetam
  • Pregabalin
  • Quetiapine
  • Reboxetine
  • Tiagabine

Not Recommended Treatments:

  • Bupropion S.R.
  • Guanfacine
  • Topiramate
  • Zolpidem
  • Alprazolam
  • Citalopram
  • Clonazepam
  • Desipramine
  • Divalproex
  • Olanzapine
  • Tiagabine

Other Treatments

Biological Therapies:

  1. Repetitive Transcranial Magnetic Stimulation (rTMS)

    • Effective as monotherapy or as an adjunct to SSRIs.
    • Demonstrated sustained improvements two to three months post-treatment.
    • Supported by randomized controlled trials (RCTs) and considered Level 1 evidence.

  2. Electroconvulsive Therapy (ECT)

    • Helpful as an adjunctive treatment for patients with refractory PTSD.
    • Based on open prospective and retrospective data, classified as Level 3 evidence.

Alternative Therapies:

  1. Acupuncture

    • More effective than a wait-list control and as effective as group CBT.
    • Supported by a randomized controlled trial, considered Level 2 evidence.

  2. Hypnotherapy

    • Symptom-oriented hypnotherapy showed improvements in PTSD symptoms in small trials.
    • Classified as Level 2 evidence.

  3. Mantra Repetition

    • Improved PTSD symptoms in small trials, offering a non-invasive treatment option.
    • Also classified as Level 2 evidence.

  4. Transcendental Meditation

    • Benefited patients with PTSD in a small case series.
    • Considered Level 4 evidence, suggesting preliminary yet promising results.

Medications with Health Canada–approved indications for anxiety and related disorders

Drugs By Condition

Panic Disorder

  • Fluoxetine (Prozac®)
  • Paroxetine (Paxil®)
  • Paroxetine CR (Paxil® CR)
  • Sertraline (Zoloft®)
  • Venlafaxine XR (Effexor® XR)
  • Benzodiazepines

First-line

  • Citalopram
  • Escitalopram
  • Fluoxetine
  • Fluvoxamine
  • Paroxetine
  • Paroxetine CR
  • Sertraline
  • Venlafaxine XR

Second-line

  • Alprazolam
  • Clomipramine
  • Clonazepam
  • Diazepam
  • Imipramine
  • Lorazepam
  • Mirtazapine
  • Reboxetine

Third-line

  • Bupropion SR
  • Divalproex
  • Duloxetine
  • Gabapentin
  • Levetiracetam
  • Milnacipran
  • Moclobemide
  • Olanzapine
  • Phenelzine
  • Quetiapine
  • Risperidone
  • Tranylcypromine

Adjunctive Therapy

  • Second-line: Alprazolam ODT, Clonazepam
  • Third-line: Aripiprazole, Divalproex, Olanzapine, Pindolol, Risperidone

Not Recommended

  • Buspirone
  • Propranolol
  • Tiagabine
  • Trazodone

Social Anxiety Disorder

  • Paroxetine (Paxil®)
  • Paroxetine CR (Paxil® CR)
  • Sertraline (Zoloft®)
  • Venlafaxine XR (Effexor® XR)

Obsessive-Compulsive Disorder

  • Fluoxetine (Prozac®)
  • Fluvoxamine (Luvox®)
  • Sertraline (Zoloft®)
  • Clomipramine

Generalized Anxiety Disorder

  • Escitalopram (Cipralex®)
  • Fluoxetine (Prozac®)
  • Paroxetine (Paxil®)
  • Paroxetine CR (Paxil® CR)
  • Venlafaxine XR (Effexor® XR)
  • Duloxetine (Cymbalta®)
  • Buspirone (BuSpar®, Buspirex®)

Posttraumatic Stress Disorder

  • Paroxetine (Paxil®)
  • Sertraline (Zoloft®)

Conditions by Drug:

Antidepressants

  1. Selective Serotonin Reuptake Inhibitors (SSRIs)

    • Escitalopram (Cipralex®) is approved for generalized anxiety disorder.
    • Fluoxetine (Prozac®) is approved for panic disorder, obsessive-compulsive disorder, and generalized anxiety disorder.
    • Fluvoxamine (Luvox®) is approved for obsessive-compulsive disorder.
    • Paroxetine (Paxil®) is approved for panic disorder, social anxiety disorder, generalized anxiety disorder, and posttraumatic stress disorder.
    • Paroxetine CR (Paxil® CR) is approved for panic disorder, social anxiety disorder, and generalized anxiety disorder.
    • Sertraline (Zoloft®) is approved for panic disorder, social anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder.

  2. Tricyclic Antidepressants (TCAs)

    • Clomipramine is approved for obsessive-compulsive disorder.

  3. Other Antidepressants

    • Venlafaxine XR (Effexor® XR) is approved for panic disorder, social anxiety disorder, and generalized anxiety disorder.
    • Duloxetine (Cymbalta®) is approved for generalized anxiety disorder.

Azapirones

  • Buspirone (BuSpar®, Buspirex®) is approved for generalized anxiety disorder.

Benzodiazepines*

  • Benzodiazepines are marked as applicable for panic disorder.

Psychotherapy Treatment

Components of cognitive behavioral interventions for Anxiety and Related Disorders

Do not combine with drug treatment by default:

current evidence does not support the routine combination of CBT and pharmacotherapy as initial treatment.

Exposure

  • Encourage patients to face fears.
  • Patients learn corrective information through experience.
  • Extinction of fear occurs through repeated exposure.
  • Successful coping enhances self-efficacy.

Safety Response Inhibition

  • Patients restrict their usual anxiety-reducing behaviors (e.g., escape, need for reassurance).
  • Decreases negative reinforcement.
  • Coping with anxiety without using anxiety-reducing behavior enhances self-efficacy.

Cognitive Strategies

  • Cognitive restructuring, behavioral experiments, and related strategies target patients’ exaggerated perception of danger (e.g., fear of negative evaluation in Social Anxiety Disorder).
  • Provides corrective information regarding the level of threat.
  • Can also target self-efficacy beliefs.

Arousal Management

  • Relaxation and breathing control skills can help patients control increased anxiety levels.

Surrender of Safety Signals

  • Patient relinquishes safety signals (e.g., presence of a companion, knowledge of the location of the nearest toilet).
  • Patients learn adaptive self-efficacy beliefs.

Special Populations

Prenant Women

Epidemiology and Impact:

  • Women are at higher risk for anxiety and related disorders compared to men, with significant attention on the perinatal period.
  • The prevalence of anxiety disorders may not change during pregnancy, but risks for specific disorders like GAD and OCD could increase, especially during the postpartum period.
  • Anxiety disorders can negatively impact pregnancy outcomes (e.g., premature delivery), the child (e.g., cognitive and emotional problems), and the mother's parenting abilities.

Treatment Considerations:

  • Psychological Treatments:
    • Strong empirical support exists for CBT in general, but specific evidence for its efficacy in perinatal women is lacking.
    • Group CBT and individual CBT have shown beneficial effects in pregnant women and postnatal women with anxiety disorders, respectively.
  • Pharmacotherapy:
    • The benefits and risks of pharmacotherapy must be carefully balanced during pregnancy and breastfeeding.
    • Antidepressants: Generally low risk for major congenital malformations; however, links to cardiac defects, preterm birth, and poor neonatal adaptation syndrome (PNAS) are noted.
    • Benzodiazepines: No significant risk for major malformations found, but possible increased risk for oral cleft and neonatal withdrawal syndrome.
    • Atypical Antipsychotics: Limited data with inconclusive risks for malformations; associated with birth weight anomalies and preterm birth.

Regulatory and Information Resources:

  • Recommendations on psychiatric medication use during pregnancy are available from ACOG and the Motherisk website.
  • The FDA and Health Canada have issued safety alerts regarding the use of antipsychotics during pregnancy due to potential risks for neonatal withdrawal symptoms.

General Guidance:

  • Decisions on treatment must weigh the risks of medication against the potential harm from untreated anxiety.
  • Treatments should be tailored individually, with the latest and most comprehensive information used to guide clinical decisions.
  • Continuous monitoring and adjustment of treatment approaches are recommended to ensure safety and efficacy.

Pediatric

Anxiety or Related Disorders Specific to Children:

  1. Separation Anxiety Disorder:

    • Developmentally inappropriate and excessive fear or anxiety concerning separation from attached individuals, indicated by three or more of the following:
      • Distress when separation occurs.
      • Worry about loss or harm resulting from separation.
      • Reluctance to leave home, be alone, or go to sleep due to fear of separation.
      • Nightmares involving themes of separation.
      • Physical symptoms (e.g., headaches, upset stomach) when separation occurs.
    • Duration: At least 4 weeks.
    • Onset: Before 18 years of age.
    • The disturbance causes clinically significant distress or impairment in social, academic, or other important areas of functioning.

  2. Selective Mutism:

    • Consistent failure to speak in specific social situations where there is an expectation to speak (e.g., at school), despite speaking in other situations.

Changes to Adult DSM-5 Diagnostic Criteria Specific to Children:

  1. Specific Phobia:

    • Fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.
    • Specifiers include loud sounds or costumed characters.

  2. SAD (Social Anxiety Disorder, Social Phobia):

    • Anxiety must occur in peer settings, not just during interactions with adults.
    • Fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failure to speak in social situations.

  3. OCD and Panic Disorder:

    • No pediatric-specific criteria.

  4. PTSD:

    • Intrusion symptoms in children may include repetitive play with themes of the traumatic event or trauma-specific re-enactment in play.
    • Frightening dreams without recognizable content.
    • Specific subtype for children less than or equal to 6 years of age.

  5. GAD (Generalized Anxiety Disorder):

    • Less stringent criteria for symptoms than in adults.

This format organizes the information into distinct categories for each disorder, clearly listing the specific symptoms and criteria relevant to children, enhancing readability and ease of use for reference.

Comorbidity

Prevalence and Impact of Comorbidities:

  • Approximately 60-80% of individuals with an anxiety disorder have at least one other psychiatric condition, such as another anxiety disorder, major depressive disorder (MDD), bipolar disorder, attention-deficit/hyperactivity disorder (ADHD), or substance use disorder (SUD).
  • Comorbid psychiatric disorders lead to more severe symptoms, poorer treatment outcomes, greater functional impairment, reduced quality of life (QoL), and increased suicide risk.
  • Medical conditions such as cardiovascular, gastrointestinal, respiratory diseases, thyroid disease, migraine, and arthritis are also frequent comorbidities with anxiety disorders, worsening disability and psychiatric symptoms.

Special Considerations for Treatment:

  • Treatments need to be effective for multiple disorders when comorbidities are present, e.g., therapies effective for both anxiety and depressive symptoms.
  • Benzodiazepines should be prescribed cautiously in patients with comorbid SUDs.
  • Treatment plans should consider the impact of untreated anxiety on both psychiatric and medical conditions.

Specific Comorbid Conditions:

  • Major Depressive Disorder (MDD): High prevalence among patients with anxiety, contributing to poorer outcomes and increased risk of suicide. SSRIs and SNRIs are recommended for treatment.
  • Bipolar Disorder or Psychoses: Significant overlap with anxiety disorders; treatment often involves atypical antipsychotics, which are effective for both bipolar disorder and anxiety symptoms.
  • ADHD: Treatment considerations involve distinguishing between primary ADHD symptoms and anxiety, with treatments potentially including stimulants or atomoxetine.
  • Chronic Pain: Duloxetine and other medications may address both anxiety symptoms and pain, such as in patients with GAD and migraines.
  • Cardiovascular Disease: Anxiety treatments must not exacerbate heart conditions, requiring careful consideration of medications that affect heart rate and blood pressure.
  • Diabetes and Metabolic Syndrome: Some psychotropic medications may affect glucose and lipid levels, necessitating careful choice of medication in anxious patients with these conditions.

Abbreviations

CR = controlled release; ODT = orally disintegrating tablets; SR = sustained release; XR = extended release.

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