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7586 Week 13, Day 2 PTSD, OCD, and Eating Disorders Slides (Snella)

Terms in this set (35)

treatment algorithm for PTSD
- diagnosis of PTSD
- SSRI for 8-12 weeks (4-6 weeks at maximum dose)

No Response:
- switch to different SSRI or venlafaxine
- if this works, continue for at least one year
- switch to different SSRI, venlafaxine, mirtazapine, or TCA
- if this works, continue for at least one year
- if this does not work, augment based on residual symptoms

Partial Response:
- augment based on residual symptoms

Response:
- continue for at least one year

RESIDUAL SYMPTOMS:
- sleep difficulties, nightmares (Prazosin)
- anger (lamotrigine)
- intrusive thoughts (risperidone, quetiapine)
- hypervigilance (risperidone, quetiapine)

**no prazosin or risperidone in VA patients
first-line medications for the treatment of PTSD
- fluoxetine (Prozac)
- paroxetine (Paxil, Pexeva)
- sertraline (Zoloft)
- venlafaxine extended-release (Effexor XR)

**use for 4 weeks, continue x4 more if partial response; if no improvement at 8 weeks, increase to max dose or change agent
second- and third-line agents for the treatment of PTSD
Second:
- amitriptyline (Elavil)
- imipramine (Tofranil)
- mirtazapine (Remeron)

Third:
- nefazodone
- phenelzine (Nardil)
dosing for fluoxetine for PTSD
- Initial: 10 mg daily
- Usual: 10-80 mg daily
dosing for paroxetine for PTSD
- Initial: 10-20 mg daily
- Usual: 20-50 mg daily

**max dose: 60 mg daily
dosing for sertraline for PTSD
- Initial: 25 mg daily
- Usual: 50-100 mg daily

**max dose: 200 mg daily
**sertraline reduced all PTSD categories of symptoms
dosing for venlafaxine extended-release for PTSD
- Initial: 37.5 mg daily
- Usual: 75-225 mg daily

**decreases numbing, avoidance, and hyperarousal symptoms
What is the concern with the second-line agents for PTSD?
- overdose
What are the concerns for the third-line agents for PTSD?
- Nefazodone: black box warning for hepatotoxicity
- Phenelzine: it's an MAOI, so adverse effects and dietary restrictions are a concern
What are the specifiers for OCD?
- With Good or Fair Insight: believes OCD beliefs are definitely/probably not true, or may/may not be true
- With Poor Insight: believes OCD beliefs are probably true
- With Absent Insight/Delusional Beliefs: believes OCD beliefs are true
- specify if tic-related
treatment algorithm for OCD
- CBT alone (13-20 sessions; better than SSRI alone)
- SSRI alone (8-12 weeks)

- CBT + SSRI
- if no response, intensify CBT, switch SSRI or to clomipramine, and/or add risperidone or aripiprazole
- if no response, switch antipsychotics, switch to duloxetine/mirtazapine, and/or use SSRI + clomipramine

- treat 1-2 years, gradually taper over months
- periodic CBT boosters every 3-6 months
first-line agents for the treatment of OCD
- citalopram (Celexa)
- escitalopram (Lexapro)
- fluoxetine (Prozac)
- fluvoxamine (Luvox, Luvox CR)
- paroxetine (Paxil, Paxil CR, Pexeva)
- sertraline (Zoloft)
second-line agents for the treatment of OCD
- clomipramine (Anafranil)
dosing of citalopram for OCD
- Initial: 20 mg daily
- Usual: 20-40 mg daily

**max dose: 40 mg daily in adults; 20 mg daily in the elderly for QTc prolongation
**DIs with CYP2C19 poor metabolizers or moderate-to-strong CYP2C19 inhibitors (e.g., cimetidine, omeprazole)
dosing for escitalopram for OCD
- Initial: 10 mg daily
- Usual: 10-20 mg daily

**doses up to 40 mg may be needed; watch for QTc prolongation
dosing for fluoxetine for OCD
- Initial: 20 mg daily
- Usual: 40-60 mg daily

**doses of 80 mg or higher may be needed
dosing for fluvoxamine for OCD
- Initial: 50 mg daily IR; 100 mg hs CR
- Usual: 100-300 mg daily for both
dosing for paroxetine for OCD
- Initial: 20 mg daily
- Usual: 40-60 mg daily

**higher doses may be needed in some patients
dosing for sertraline for OCD
- Initial: 50 mg daily
- Usual: 50-200 mg daily

**higher doses may be needed in some patients
class, MOA, and dosing for clomipramine
Class: dibenzazepine TCA

MOA: TCA, includes 5-HT reuptake inhibition

Dosing:
- Initial: 25 mg/day PO/HS; may increase to 100 mg/day during first two weeks
- Max: 250 mg/day
- hepatic and renal dysfunction may require dose reductions
warnings, contraindications and Beer's criteria for clomipramine
Warnings:
- black box warning for suicidal thinking

Contraindications:
- concurrent use of MAOIs within 14 days
- acute MI

Beer's Criteria:
- avoid in the elderly due to anticholinergic ADRs and sedation
DIs and ADRs of clomipramine
DIs:
- MAOIs (serotonin syndrome)
- lithium (serotonin syndrome)
- QT-prolonging drugs
- NSAIDs/ASA (bleeding)

ADRs:
- anticholineragic side effects
dosing for aripiprazole for OCD
- 5 mg po daily
- may increase in 5 mg increments up to 15 mg/day
DIs and ADRs for aripiprazole
DIs:
- CYP3A4/5 inducers/inhibitors

ADRs:
- akathisia
- anxiety
- extrapyramidal side effects
- headache
- increased appetite
- somnolence
- weight gain
- hyperglycemia
risperidone MOA, DIs, and ADRs
MOA:
- potent serotonin 5-HT2 antagonist
- weaker dopamine-D2 antagonist
- 2nd generation antipsychotic

DIs:
- CYP2D6, P-glycoprotein inhibitors (decreased risperidone metabolism)
- P-glycoprotein inducers (increase risperidone excretion)
- QT-prolonging drugs
- valproic acid (increased valproic acid concentrations)
- anticholinergics (enhance activity)

ADRs:
- extrapyramidal side effects
- insomnia
- anxiety
- fatigue
- metabolic changes
Define Anorexia Nervosa (AN) and list symptoms.
- restriction of energy intake that leads to low body weight and self-evaluation that is influenced by perceptions of weight and body shape

Symptoms:
- obsessions and fears about eating and gaining weight
- complains about feeling full even when they have eaten very little food
- denial of symptoms, failure to recognize low body weight, and low self-esteem
- feelings of ineffectiveness and lack of self-control
Define Bulimia and list symptoms.
- binge-eating which stops with abdominal pain or self-induced vomiting or interruption by another person
- pattern of severe dieting followed by binge-eating episodes
- concerned about body image

Symptoms:
- does not eat regular meals and does not feel satiety at the end of a meal
- may use purging methods such as laxatives
- feelings of guilt, depression, and self-disparagement after binges
- social isolation can result from frequent bingeing
- chaotic and troubled personal relationships and substance use are common
treatment of AN
Hospitalization:
- rapid weight loss or BMI <12
- reduced PO intake (sudden/persistent)
- HR <40 or >120
- BP <90/60
- BG <60
- decreased protein
- potassium <3.0
- hypothermia, edema
- comorbid psychiatric condition
- non-responsive to 3-6 months of treatment
- demoralization or non-functional family
- patient denial
- continuous supervision required

**non-hospitalization involves psychotherapy for 6-12 months and oral refeeding; no antidepressants should be used
treatment options for BN
Non-Pharmacologic:
- nutritional rehabilitation, education, and counseling
- CBT (alone or in combination with fluoxetine)
- if CBT fails, consider interpersonal psychotherapy
- if interpersonal psychotherapy fails, consider family and/or group therapy

Pharmacologic:
- antidepressant therapy (preferred agent: fluoxetine)
- failed preferred antidepressant therapy: consider sertraline
- failed preferred and secondary agent: consider other SSRI or SNRI
- failed antidepressant therapy: consider topiramate

Comorbid Psychiatric Diagnoses Present:
- bipolar (consider divalproex, olanzapine, quetiapine, risperidone)
- schizophrenia (consider olanzapine, quetiapine, risperidone)
- depression (consider fluoxetine, sertraline)
- ADHD (consider methylphenidate)
Define Binge Eating Disorder (BED).
- repeated episodes of bing-eating that includes a lack of self-control and eating an amount of food that is beyond what most people would eat
- episodes of bing-eating may include rapid eating, a sense of fullness to the point of being uncomfortable, eating when not hungry, eating alone secondary to feeling embarrassed, and a sense of self-disgust, depression, or guilt
signs and symptoms of BED
Symptoms:
- episodes of binge-eating
- lack of self-control
- rapid consumption of food
- feeling full and eating when not hungry
- isolation and guilt/depression

Signs:
- obesity
- history of weight loss followed by weight gain
- binge-eating without compensatory purging
- comorbid psychiatric and medical complications
psychotherapy for BED
Antidepressants (SSRIs):
- fluoxetine
- fluvoxamine
- sertraline
- citalopram
- escitalopram

Stimulants:
- lisdexamfetamine
- atomoxetine
- methylphenidate

Topiramate
dosing for lisdexamfetamine for moderate-to-severe BED
- 30 mg po daily in the morning
- may titrate weekly in 20 mg increments to 50-70 mg po daily
MOA, warnings, and contraindications for lisdexamfetamine (Vyvanse)
MOA:
- prodrug of dextroamphetamine

Box Warnings:
- risk of abuse, misuse, and diversion

Contraindications:
- hypersensitivity/idiosyncrasy to sympathomimetic amines
- MAOIs
- symptomatic CV disease or advanced arteriosclerosis
- moderate-to-severe HTN
- hyperthyroidism
- glaucoma
- agitated states
- history of drug dependence
DIs, ADRs, and clinical pearls for lisdexamfetamine (Vyvanse)
DIs:
- TCAs (increased risk of CV events)
- MAOIs (increased risk of hypertensive crises)

ADRs:
- insomnia
- irritability
- loss of appetite
- upper abdominal pain
- xerostomia

Clinical Pearls:
- amphetamines have a high potential for abuse
- long periods of use may lead to dependence
- misuse of amphetamines can cause sudden death and serious CV events
- a complete family and patient history for conditions associated with sudden cardiac death is required
- a complete physical evaluation of the patient for HTN, cardiac murmurs, physical findings associated with Marfan syndrome, and signs of irregular cardiac rhythms should be conducted
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