OCD, PTSD, and Panic Disorders

OCDBiological basis remains unknown

But there seems to be some genetic component related to OCD and other anxiety disorders

Meds ameliorate but do not eliminate symptoms in many patients

Relapse is common after discontinuation of Medication

Anafranil/Clomipramine Discovered to be effective in the mid 1980s

Is a potent nonselective serotonin reuptake inhibitor

Led to the 5HT theory for OCD

Led to the use and efficacy of SSRIs

Dopamine Up to 40% of OCD patients do not respond

to SSRIs Cocaine worsens compulsions in Tourette

syndrome Family studies show OCD and Tourettes are

linked leading Use of older antipsychotics that block DA

receptors added to ongoing SSRI tx reduces severity of symptoms in tx resistant clients (especially those with Tourettes)

Serotonin and Dopamine

Atypical antipsychotics Work SSRIs in some clients Have no effect on other clients And worsen symptoms in some clients

OCD and….

Tourettes = conventional antipsychotics and SSRIs

Depression = higher doses of SSRIs Longer delayed onset = 6-12+ weeks Results in depression=remission and in

OCD are about 35% reduction, with relapse after discontinuation

SSRIs appear to work via a different mechanism with OCD than Depression

OCD adjunct treatments Handout of page 342 (hypothetic, not

proven) Augment with serotonergic agents Add benzodiazepine (clonazepam) to

help tolerate high dose of SSRI, to reduce anxiety, and enhance serotonin

Behavioral Therapy Psychosurgery

Panic Attacks and Panic Disorder

Biological Theories Norepinephrine- dysregulation in this

system (too much initially?) GABA- out of balance. The body

produces natural benzos and these may be limited or inverse agonists may be excessive or receptors may be abnormal

Abnormal Respiratory functioning and Lactate sensitivity

False suffocation alarm theory- opposite disorder is Ondine’s Curse where one has diminished sensitivity of the suffocation alarm and they lack adequate breathing (esp. when asleep)

Caffeine increases panic attacks Alcohol can increase panic attacks Pot can increase anxiety (even

though it is often used initially to keep anxiety under control)

Treatments SSRIs-First Line

3-8 weeks to work (same as antidepressant effects) Start with lower does due to Panic People being more

sensitive to antidepressants Increase to same or higher doses as antidepressants

to gain effects

Newer Antidepressants-Not approved, but promising Effexor and Reboxitine (how does this contradict the Norepinephrine theory?)-Second Line

Welbutrin may increase anxiety and agitation

Treatment TCAs- Imipramine and Clomipramine-Third

line Benzodiazepines- adjunct treatment

Rapid effect Cause cognitive slowing Addiction issues Withdrawal issues

High potency better (alprazolam, clonazepam) than low potency (diazepam, lorazepam) due to low potency benzos frequently resulting in sedation prior to adequate relief of panic and anxiety

Treatment Bezos (cont) (can be used for immediate

relief or build up in system) Alprazolam-very effective, short duration,

administered 3-5x’s a day Clonazepam- longer duration, twice a day, less

abuse potential, longer half lie so easier to taper. Weigh consequences of inadequate tx (physical,

loss of social and occupational functioning, suicide) against risks for each individual

Treatment for Panic should include therapy

CT and CBT Educate about anticipatory anxiety Work with Catastrophizing Work with high attention to bodily signs Help cl understand use of medications and

effects Help cl to regulate physiological system with

deep relaxation training Exercise-inducing panic and reducing anxiety

(Panic and GAD seem to develop from separate systems)

Relapse

Relapse rate is high when treatment is stopped

Panic disorder is a chronic disorder that most often requires maintenance treatment

Social Phobia Paxil SSRIs- first line Effexor Not a lot of evidence for TCAs MAOs- 4th line tx Benzos- Clonazepam, a possibility Beta Blockers Buspar and Clonidine-no clear studies of

efficacy

PTSD Historically the focus has been on

symptoms (depression, insomnia, etc) SSRIs- First line TCAs and MAOs –second line Beta blockers and mood stabilizers-

some clinical support Benzos- with care, due to high

concomitant A & D