ANXIETY/WORRY ± PANICS

Palpitation Ambulation (dizzy) Numb-Nausea

Intense fear of death-derangement-derealization

Choking-Chills-Chest pain Sweating-Shaking-Short of breath

A panic attack is a sudden, intense episode of anxiety/fear with ≥4 severe symptoms that may greatly resemble a heart attack

Panic attacks may be present in any disorder but are required in panic disorder

FEAR

DIAGNOSIS

MINIMUM CRITERIA

Almost everything

Generalized anxiety disorder

STRIFE (6 months)

3 of Sleep, Tension, Restlessness, Irritability, Focus, Energy

Children only require 1 symptom

Social scrutiny

Social phobia

Intense fear/avoidance (6 months) Of social judgment

Panic attacks

Panic disorder

Recurrent/unexpected panic (1 month)

Fear of more panic attacks

And/or avoidance of triggers

Leaving home

Agoraphobia

Intense fear/panic (6 months)

2 of public transit, open spaces, closed spaces, crowds, being alone outside

Very specific

Specific phobia

Intense fear/avoidance (6 months) Of specific object/situation

Speaking

Selective mutism

Unwilling to speak (1 month)

Able/willing to speak in other locations

Not only during first month of school

Separation

Separation anxiety disorder

Intense fear (6 months)

3 of separation, ill parent, getting lost or ill, leaving home, staying home, going to sleep, bad dreams

Children only require 1 month

Additional Anxiety Disorders

Other specified

Not quite meeting full criteria

Unspecified

Limited or conflicting information

Substance/medication induced

Due to another medical condition

RATING SCALES

Adults

GAD-7

Generalized Anxiety Disorder-7 Specifically for GAD but can be used for other disorders 10-14 moderate, 15-21 severe

Children

Scared^a

Screen for Child Anxiety Related Disorders

≥25 may indicate anxiety disorder

Subscores: A positive screen may indicate disorder

Somatic symptom disorder: ≥7

Generalized anxiety disorder: ≥9

Separation anxiety disorder: ≥5

Social anxiety disorder: ≥8

School avoidance: ≥3

SPECIFIERS

Social phobia

Performance only: anxiety symptoms only prominent during public speaking or performance

Specific phobia

Animal: eg, spiders, insects, dogs

Natural: eg, heights, storms, water

Blood-injection: eg, needles, medical procedures

Situational: eg, airplanes, elevators

Other: eg, choking, clowns

DIFFERENTIAL DIAGNOSIS

Medical

CAD, CHF, COPD, PE, MVP, Cushing disease, arrhythmias, hypertensive emergency, pneumonia, asthma, thyroid dysfunction, hyperparathyroidism, hypoglycemia, menopause, insulinoma, pheochromocytoma, anemia, seizure disorder, encephalopathy, essential tremor

Mental

MDD, PTSD, OCD, SUD, somatic symptom disorder, personality disorder

Meds or substance

Bupropion, caffeine, nicotine, cocaine, amphetamines, PCP, sympathomimetics, beta-2-agonists, dopamine agonists, metoclopramide, anticholinergics, steroids, indomethacin, withdrawal (alcohol, opioids, sedatives, antidepressants)

^a Validated: but not listed in AIMS/SAMHSA/AHRQ recommendations

INITIAL APPROACH

Mild

Moderate

Severe/complex

Psychotherapy

Meds and/or therapy

Medication

Secondary/co-occurring: treat medical/substance use simultaneously Psychotherapy: see psychotherapy section for details

BZDs are “anti-panic” and are best used short-term or infrequently PRN

Chronic severe anxiety/panic is best treated with psychotherapy and/or SSRI/SNRIs

In patients not on opioids or with SUDs, BZDs can be initiated while waiting for other treatment to take effect, with the agreement that they will not be used long-term or as monotherapy

MEDICATION CHOICE

Choose by class, side effects, and contraindications

WEIGHT GAIN AND SEDATION

Lowest in class

Moderate

Highest in class

MEDS BY CLASS

SIDE EFFECTS AND SAFETY

1) Buspirone

Low sex side effects but no antidepressant properties

Buspirone 10-30 BID

Mild side effects but must dose BID

2) SSRI

Best for anxiety but worst sex side effects

Fluoxetine 10-80

Least withdrawal and longest half-life

Sertraline 25-200

Best for pregnancy and breast feeding

Citalopram^a 20-40 or escitalopram 10-20

Low side effects overall

Long QT >40 mg (citalopram only)

Paroxetine 10-60 HS or ER 12.5-62.5 HS

Good for anxiety but worst withdrawal

ER form may have less withdrawal

Pregnancy

3) SNRI and related

Good for pain but often worst nausea

Venlafaxine ER 37.5-225 or desvenlafaxine 25-100

May help hot flashes but bad withdrawal

Duloxetine 20-120

Bad withdrawal and ± formulary

4) Psych referral

For psychotherapy or additional meds

Common side effects: stimulation/sedation, stomach upset, headache, dry mouth, sexual

^a Off-label: evidence-based but no FDA indication

INSTRUCTIONS

Increase

Add

Cross

Try

Treat

At 1 week then Q2-4 until remission or intolerable

Augmentation for partial effect at 75%-100% max dose

To next if no effect at 50% max dose for 4 weeks

2 meds per class (if possible) before moving to next

For 6 months for 1 episode, 12 for 2, lifelong for ≥3

Reduce dosing by 50% if <18, >65, or severe liver or kidney disease

AUGMENTATION

All

▼ substance use and ▲ treatment of sleep and pain

Add meditation, exercise, and/or psychotherapy

Persistent anxiety

1) Buspirone 10-30 BID

2) Clonazepam 0.5-2 daily or div BID (short-term)

PRN anxiety

1) Lorazepam 0.5-3 div TID (short-term) or safer alternative hydroxyzine^a 25-100 TID (if SUD/opiates)

Performance anxiety: propranolol^a 10-40 (1 hour prior)

PSYCHOTHERAPY & RESOURCES

Mindfulness (including relaxation techniques) and CBT (including behavioral activation and problem-solving treatment)

The Anxiety and Worry Workbook—Clark/Beck

The Anxiety and Phobia Workbook—Bourne

When Panic Attacks—Burns

The Anxiety Workbook for Teens—Schab

On Edge: A Journey Through Anxiety—Petersen

Adaa.org—Anxiety and Depression Association of America

CONTRAINDICATIONS & MONITORING

Citalopram

Clonazepam

Lorazepam

Paroxetine

Propranolol

Long QT >40 mg

Pregnancy, SUD, sedative/opiate use

Pregnancy, SUD, sedative/opiate use

Pregnancy

Bradycardia, asthma, heart failure

See safety and monitoring in appendix for additional information

^a Off-label: evidence-based but no FDA indication

OBSESSION AND/OR COMPULSION

Obsessions are intense, unwanted ideas, urges, or images

Compulsions are rituals performed to either undo or prevent obsessions or some other impending disaster

Obsessive-compulsive personality disorder is distinct in that the patient feels that the rigid rules are necessary, pervasive, and a part of who they are (may be difficult to distinguish from OCD with absent insight/delusional beliefs)

SYMPTOMS

DIAGNOSIS

MINIMUM CRITERIA

Washing, checking, symmetry, etc

Obsessive-compulsive disorder

Obsessions and/or compulsions 1 hour or more a day

Physical flaws

Body dysmorphic disorder

Focus on perceived flaws

Includes repetitive behaviors hiding, comparing, repairing flaws

Collecting

Hoarding disorder

Distress in discarding objects

Due to perceived need to save them

Often leading to accumulation

May include animals

Skin picking

Excoriation disorder

Frequent skin picking

With difficulty stopping

Can be during stress (focused) or when distracted (automatic)

Hair pulling

Trichotillomania

Frequent hair pulling

With difficulty stopping

Can be during stress (focused) or when distracted (automatic)

Additional Obsessive-Compulsive and Related Disorders

Other specified

Not quite meeting full criteria

Unspecified

Limited or conflicting information

Substance/medication induced

Due to another medical condition

RATING SCALES

Obsessive-Compulsive Disorder

Y-BOCS^a

Yale-Brown Obsessive Compulsive Scale-II

Symptom checklist: generates a symptoms list

Severity rating scale: quantifies symptoms over time

16 moderate, 24 severe, 32 extreme

CY-BOCS^a

Children’s Yale-Brown Obsessive Compulsive Scale

Symptom checklist: generates a symptoms list

Includes self- and clinician-rated versions

Severity rating scale: quantifies symptoms over time

Includes child-, parent-, and clinician-rated versions 16 moderate, 24 severe, 32 extreme

SPECIFIERS

OCD

Tic-related: current or past history of tic

BDD

With muscle dysmorphia: focused on muscle size

Hoarding

With excessive acquisition: due to difficultly discarding

All

With good or fair insight: aware that beliefs are not true

With poor insight: feel that beliefs are probably true

With absent insight/delusional beliefs: beliefs are true

DIFFERENTIAL DIAGNOSIS

Medical

TBI, stroke, hypothyroidism, meningitis, encephalitis, dementia, genetic disorder

Mental

MDD, PTSD, social phobia, specific phobia, agoraphobia, paraphilia, substance use, panic disorder, tic disorder, illness anxiety disorder, delusional disorder, bipolar disorder, personality disorders, autism spectrum disorders, impulse control disorders, eating disorders

Meds or substance

PCP, stimulants, sympathomimetics, dopamine agonsists, steroids, hallucinogens, withdrawal (alcohol, opioids, sedatives)

^a Validated: but not listed in AIMS/SAMHSA/AHRQ recommendations

INITIAL APPROACH

Mild

Moderate

Severe/complex

Psychotherapy

Meds and/or therapy

Medication

Secondary/co-occurring: treat medical/substance use simultaneously

Psychotherapy: see psychotherapy section for details

Response to meds: OCD>OCD-related >> OCPD

MEDICATION CHOICE

Choose by class, side effects, and contraindications

WEIGHT GAIN AND SEDATION

Lowest in class

Moderate

Highest in class

MEDS BY CLASS

SIDE EFFECTS AND SAFETY

1) SSRI

Best for anxiety but worst sex side effects

Fluoxetine 10-80

Least withdrawal and longest half-life

Sertraline 25-200

Best for pregnancy and lactation

Citalopram^a 10-40 or escitalopram^a 5-20

Low side effects overall

Long QT >40 mg (citalopram only)

Paroxetine 10-60 HS or ER 12.5-62.5 HS

Good for anxiety but worst withdrawal

ER form may have less withdrawal

Pregnancy

2) Fluvoxamine (SSRI)

Best for OCD but multiple interactions

Fluvoxamine 25-200 BID or ER 50-400 HS

Must dose BID (IR form)

ER form is single dose but ± formulary

3) Clomipramine (TCA)

Best for OCD but sedating/constipating

Clomipramine 25-250 HS

Pregnancy, MI

4) SNRI & related

Good for pain but often worst nausea

Venlafaxine ER^a 37.5-225 or desvenlafaxine^a 25-100

May help hot flashes but bad withdrawal

Duloxetine^a 20-120

Bad withdrawal and ± formulary

Mirtazapine^a 7.5-45 HS

Least nausea and good for sleep/anxiety

Most sedation and weight gain

5) Psych referral

For psychotherapy or additional meds

Common side effects: stimulation/sedation, stomach upset, headache, dry mouth, sexual

^a Off-label: evidence-based but no FDA indication

INSTRUCTIONS

Increase

Add

Cross

Try

Treat

At 1 week then Q2-4 until remission or intolerable

Augmentation for partial effect at 75%-100% max dose

To next if no effect at 50% max dose for 4 weeks

2 meds per class (if possible) before moving to next

For 1-2 years then attempt 10% taper monthly

Reduce dosing by 50% if <18, >65, or severe liver or kidney disease

AUGMENTATION

All

▼ substance use and ▲ treatment of sleep and pain

Add meditation, exercise, and/or psychotherapy

OC disorders

1) Try up to 150% standard max dose of primary agent

2) Risperidone^a 0.5-3 HS

3) Add/use clomipramine 25-250 HS

Tic or Tourette syndrome

1) Clonidine^a 0.05-0.2 BID or ER^a 0.05-0.4 HS

2) Or less sedating guanfacine^a 0.5-2 BID or ER^a 1-4

3) Tetrabenazinea 12.5-25 BID or SGAa

PSYCHOTHERAPY & RESOURCES

CBT: OCD, BDD, hoarding, trichotillomania, and excoriation

Exposure and response prevention: OCD and hoarding

Habit reversal treatment: trichotillomania and excoriation

Getting Over OCD—Abramowitz

Buried in Treasures—Tolin/Frost/Steketee

Overcoming BDD—Neziroglu/Khemlani-Patel/Santos

Trichotillomania—Woods/Twohig

Skin Picking—Pasternak

The Man Who Couldn’t Stop—Adam

Iocdf.org—International OCD foundation

CONTRAINDICATIONS & MONITORING

Citalopram

Clomipramine

Paroxetine

Tetrabenazine

Long QT (>40 mg)

Pregnancy, MI

Pregnancy

Long QT, liver failure, arrhythmia

Initial monitoring: TCA=EKG (>40 or cardiac disease); SGA=HA1c, lipids, EKG (if cardiac risk factors)

See safety and monitoring in appendix for additional information

^a Off-label: evidence-based but no FDA indication

TRAUMA

Trauma exposure

Re-experiencing

Arousal increase

Unpleasant Mood

Avoidance

To actual or threatened serious injury or death Nightmares, flashbacks, or intrusive memories With ▲ startle, vigilance, irritability, or insomnia Including depression, detachment, or amnesia Of stimuli associated with trauma memory

PTSD can follow a single trauma or prolonged/repeated exposures

Complex/childhood trauma may present less like PTSD and more like a collection of other pathologies including MDD, bipolar, anxiety, substance use, or personality disorder

Not all trauma leads to clinical difficulties or a psychiatric diagnosis Trauma symptoms will often decrease over time, but may remain latent or reoccur

SYMPTOMS

DIAGNOSIS

MINIMUM CRITERIA

Minor acute

Adjustment disorder

1-4 symptoms Distress that is out of proportion Or significant impairment in function Usually from 3-6 months from trigger

Major acute

Acute stress disorder

All 5 symptoms (≤30 days)

Major chronic

Posttraumatic stress disorder

All 5 symptoms (>30 days)

Usually within 6 months of trauma

Inhibited child

Reactive attachment disorder

Inhibited behavior toward adults Due to persistent neglect or abuse Social and emotional negativity

Disinhibited child

Disinhibited social engagement disorder

Disinhibited behavior toward adults Due to persistent neglect or abuse

Not due to ADHD

Additional Trauma- and Stressor-Related Disorders

Other specified

Not quite meeting full criteria

Unspecified

Limited or conflicting information

RATING SCALES

Posttraumatic Stress Disorder

PC-PTSD

Primary Care PTSD Screen Used for screening and diagnosis only ≥3

NSESS^a

National Stressful Events Survey PTSD Short Scale

Used to follow symptom severity over time

0-36 (with higher scores indicating greater severity)

SPECIFIERS

Adjustment Disorder

Type

With anxiety: anxiety/nervousness/worry prominent

With depressed mood: low mood/tearfulness prominent

With disturbance of conduct: acting out prominent

With mixed anxiety and depressed mood: both

With mixed disturbance of emotions and conduct: all

Timing

Acute: <6 months of symptoms

Persistent (chronic): ≥6 months of symptoms

PTSD

Type

With dissociative symptoms: feel unreal/outside body

Timing

With delayed expression: no symptoms until 6 months after trauma

DIFFERENTIAL DIAGNOSIS

Medical

Traumatic or anoxic brain injury, postconcussive syndrome

Mental

MDD, OCD, anxiety, psychosis, substance use, dissociative disorders, personality disorders

Meds or substance

Bupropion, caffeine, nicotine, cocaine, amphetamines, PCP, sympathomimetics, withdrawal (alcohol, opioids, sedatives, antidepressants)

^a Validated: but not listed in AIMS/SAMHSA/AHRQ recommendations

INITIAL APPROACH

Mild

Moderate

Severe/complex

Psychotherapy

Meds and/or therapy

Medication

Secondary/co-occurring: treat medical/substance use simultaneously

Psychotherapy: see psychotherapy section for details

Adjustment & Acute Stress Disorder

Treat severe target symptoms for 30 days before attempting taper

Insomnia only

PRN panic attacks

24-hour anxiety

Zolpidem 5-10 HS

Lorazepam 0.5-1 up to TID

Clonazepam 0.25-1 up to BID

Posttraumatic Stress Disorder

A) Start alpha blocker if combat-related or re-experiencing dominant

B) Start SSRI if mood and avoidance dominant (or co-occurring MDD)

Titrate A or B to 75%-100% of max dose then augment with other (A/B)

If all symptoms severe, start both types of medication initially (A + B)

WEIGHT GAIN AND SEDATION

Lowest in class

Moderate

Highest in class

A1) Alpha blocker

Best for re-experiencing but common ▼ BP

Re-experiencing and hyperarousal

Prazosin^a 1-15 HS (or 1-7 BID if AM ≥ PM)

If ▼ BP/dizzy

Doxazosin^a 1-15 HS

A2) SGA

Less ▼ BP but ▲ lipids/weight gain

Risperidone^a 0.5-4 HS

Quetiapine^a 25-400 HS

Olanzapine^a 5-20 HS

B1) SSRI

Best for anxiety but worst sex side effects

Fluoxetine^a 10-80

Sertraline 25-200

Paroxetine 10-60 HS or ER 12.5-62.5 HS

B2) SNRI & related

Good for pain but often worst nausea

Venlafaxine ER^a 37.5-225

Mirtazapine^a 7.5-45 HS

3) Psych referral

For psychotherapy or additional meds

Common side effects: stimulation/sedation, stomach upset, headache, dry mouth, sexual (SSRI/SNRI); ▼ BP/dizziness (prazosin/doxazosin); fatigue, dry mouth, stomach upset, increased appetite/weight gain, feeling foggy-headed, muscle restlessness/stiffness (SGA)

^a Off-label: evidence-based but no FDA indication