Behavioral Health Clinical Practice Guidelines for: Anxiety, Obsessive-Compulsive and Related Disorders in Children and Adults OBJECTIVE

To guide the appropriate diagnosis and treatment of Anxiety Disorders in Children and Adults.

DIAGNOSIS & ASSESSMENT MEETS DSM-5 DIAGNOSTIC CRITERIA FOR ASSESSMENT • • Hoarding Disorder • It is recommended that practitioners screen for anxiety • Disorder • symptoms, rate the severity, rate the impairment to • Specific • Excoriation Disorder functioning, and assess for co-morbid disorders, including underlying medical conditions and psychiatric diagnoses (like • Generalized ADHD or ). • Obsessive Compulsive Disorder • Review any substance induced condition such as excess caffeine intake (coffee, soda, chocolate), nicotine or other substances that increase anxiety symptoms. Scales such as the Beck Anxiety Inventory, the Multidimensional Anxiety Scale for Children, the Y-BOCS and CY-BOCS are useful • Complete full medical, developmental, school, and psychiatric for obtaining baseline data on severity and can be used for history. monitoring progress. Visit MDwise.org for rating scale links. TREATMENT GUIDELINE-DIRECTED TREATMENT those wishing to consider pharmacological intervention, SSRIs are the recommended therapeutic choice. Anticonvulsants, TCAs, The National Institute for Health and Care Excellence (NICE) benzodiazepines, and antipsychotics should not be routinely offered guidelines provide a stepped approach for the disease states for the treatment of SAD. below: • Generalized Anxiety Disorder (GAD) - Those that have • Obsessive Compulsive Disorder (OCD) - Initial approach should found no improvement with low-intensity psychological be low-intensity or high-intensity psychological intervention, interventions (individual non-facilitated self-help, individual depending on severity of the OCD. A SSRI should also be guided self-help, or psychoeducational group therapy) considered for those with moderate to severe functional impairment should be considered for individual high-intensity in coordination with psychological intervention. Benzodiazepine use psychological intervention (cognitive behavioral therapy for the treatment of OCD is not recommended within this guideline. (CBT) or applied relaxation) and/or drug treatment. • Post-Traumatic Disorder (PTSD) - All PTSD sufferers should Selective serotonin reuptake inhibitors (SSRIs) should be be offered a course of trauma-focused psychological treatment. For offered as first-line drug therapy. Serotonin-noradrenaline those requiring pharmacological intervention, mirtazapine, paroxetine, reuptake inhibitors and pregabalin can be considered upon amitriptyline, and phenelzine have evidence of clinically or statistically failure of or intolerance to a SSRI. Benzodiazepines are not significant benefits. For those with sleep interruption due to PTSD, recommended for the treatment of GAD in primary or sedative-hypnotics may be appropriate for short-term use only. secondary care except as a short-term measure during a Benzodiazepine use for the treatment of PTSD is not recommended crisis. Antipsychotics are also discouraged for the treatment within this guideline. of GAD. THERAPY • Panic Disorder - For patients with mild to moderate panic Cognitive behavioral therapy (CBT) is well accepted by patients and has disorder, low-intensity interventions may be sufficient. Those been well researched. with moderate to severe panic disorder should be considered for CBT or pharmacological intervention. The There are different forms of cognitive behavioral therapy that have been evidence base suggests SSRI or tricyclic antidepressant developed for the various disorders. Mindfulness-based psychotherapies have also been shown to improve functioning and decrease fear based (TCA) therapy for longer-term management of panic anxiety symptoms. disorder. Benzodiazepines are associated with a less positive outcome with long-term use and should not be prescribed • CBT can be used in combination with medication management for the treatment of panic disorder. NICE guidelines also or alone. discourage the use of sedating antihistamines or • CBT is first line treatment for mild-moderate cases when antipsychotics for treatment. possible. • (SAD) - CBT is recommended • CBT and SSRIs are evidenced based treatments for children. as the initial treatment option for adults with SAD. For Continued on next page THERAPY CONTINUED • Involve parent in treatment if patient is a child or adolescent. • If patient is discharged from inpatient hospitalization, patient needs to be seen in an outpatient setting, intensive outpatient setting or partial hospitalization by a behavioral health provider within 7 calendar days. • Address co-morbid diagnoses. Treatment recommendations do not guarantee coverage of services.

REFERENCES Barlow, David H. & Cruske, Michelle, G. (2006) Mastery of Your Anxiety and Panic-4th ed. Oxford University Press. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013). American Psychiatric Association. NIMH (2008) Study Identifies Three Effective Treatments for Childhood Anxiety Disorders. Website. NIMH (2008) Treatment of Anxiety Disorders. Website. Rosenbaum, JF; Labbate, LA; Arana, GW; Hyman,SE; Fava, M (2005) Handbook of Psychiatric Drug Therapy. Lippincott Williams & Wilkins. Journal of the American Academy of Child and Adolescent Psychiarty (2007), 46(2): 267-283. Journal of the American Academy of Child and Adolescent (2012), 51(1):98-113. Koran, LM; Simpson, HB (2013) Guideline Watch: Practice Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder. American Psychiatric Association. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4480225/ Generalized anxiety disorder and panic disorder in adults: Management. (2011, January). Retrieved September 2018, from https://www.nice.org.uk/guidance/cg113/chapter/1-Guidance#stepped-care-for-people-with-gad

Approved by the Medical Advisory Council on 12/10/2008 Revised: 01/2020 Approved by MAC: 8/12/15 APP0214 (7/20) Reviewed 2/2020