The Anxiety Disorders A Patient-Centered, Evidence-Based Diagnostic and Treatment Process1 Kendall L. Stewart, MD, MBA, DLFAPA September 20, 2013 1 This is problem-oriented learning with numerous links to supporting resource material. Why should you learn about these disorders? • • • • They are the most common mental disorders. These disorders are frequently missed, ignored or mistreated. These disorders cause substantial distress and impairment.1 Patients with these disorders over-utilize other medical services.2,3 • Many physicians still lump these disorders and minimize them as “nerves.” • These disorders can usually be effectively treated. 1 Significant distress and/or impairment are required to make a psychiatric diagnosis. and depression are frequently masked by physical complaints. 3 One of my elderly patients never talked about her anxiety, only the “burning in my head.” 2 Anxiety What are some of the physical manifestations of anxiety? • Diarrhea • Dizziness or lightheadedness • Hyperhidrosis • Hyperreflexia • Hypertension • Palpitations • Pupillary mydriasis 1 Most • • • • • • Restlessness Syncope Tachycardia Tingling in the extremities Tremors1,2,3 Upset stomach (“butterflies”) • Urinary frequency, hesitancy, urgency tremors are worsened by anxiety. admitted a man from the ED who developed a significant conduction disturbance. 3 I unexpectedly experienced panic when undergoing MR imaging. 2I What are some of the mental manifestations of anxiety? • • • • • • • • • • • Apprehension Vigilance Scanning Shame Confusion Distortion of perception Decreased concentration Poor recall Impaired association Selective inattention False assumption1,2 1 Anxious 2 One patients always assume the worst. of my patients noted, “You don’t look so good.” What clinical algorithm1,2 will assist you in making a correct anxiety diagnosis? Anxiety “Normal” Anxiety Anxiety Disorders Anxiety 2o to Gen Med Cond SubstanceInduced Anxiety Anxiety Assoc With Another Mental Disorder Specific Phobia Social Anxiety Disorder Panic Disorder COPD Sedatives Pulmonary Embolism Anesthetics CHF Stimulants Dissociative Disorder OCD Hypothyroidism Alcohol Cognitive Disorder Adjustment Disorders PTSD Hypoglycemia Caffeine Mood Disorder Etc. Etc. Etc. Etc. Etc. Agoraphobia Gen Anxiety Disorder 1 These categories form an excellent conceptual algorithm for evaluating psychiatric symptoms in clinical practice. 2Always remember to ask about caffeine. What is the difference between normal and pathologic anxiety? • It is often impossible to tell at the time. • Consider whether the anxiety or fear promotes adaptation or causes impairment. • Consider the trigger, the duration and the degree of impairment. • Whether a given distress is judged normal or pathologic depends on one’s resources, psychological defenses, and coping mechanisms.1,2 • “Is this more than the usual ups and downs of life?” will often point the physician in the right direction. 1 Strong emotion of any sort impairs your ability to think clearly and act rationally. of my patients came out of the restroom to find the atrium door locked. The sign on my door may have discouraged potential rescuers. All she needed to do was turn the deadbolt and walk out. 2 One What disorders are included in the Anxiety Disorders category? • • • • • • • • • • • • Separation Anxiety Disorder Selective Mutism Specific Phobia Social Anxiety Disorder (Social Phobia) Panic Disorder Panic Attack Specifier (not a diagnosis) Agoraphobia Generalized Anxiety Disorder Substance/Medication-Induced Anxiety Disorder Anxiety Disorder Due to Another Medical Condition Other Specified Anxiety Disorder Unspecified Anxiety Disorder What disorders are included in the Obsessive-Compulsive category? Obsessive-Compulsive Disorder Body Dysmorphic Disorder Hoarding Disorder Trichotillomania (Hair-Pulling Disorder) Excoriation (Skin-Picking) Disorder Substance/Medication-Induced Obsessive-Compulsive and Related Disorder • Other Specified Obsessive-Compulsive and Related Disorder • Unspecified Obsessive-Compulsive and Related Disorder • • • • • • What disorders are included in the Trauma- and Stressor-Related category?1,2 Reactive Attachment Disorder Disinhibited Social Engagement Disorder Posttraumatic Stress Disorder Acute Stress Disorder Adjustment Disorders Other Specified Trauma- and Stressor-Related Disorder • Unspecified Trauma- and Stressor-Related Disorder • • • • • • 1A 2If number of us are concerned about diagnosis inflation. you would like to read more about this concern, read Saving Normal by Allen Frances. What is the epidemiology of anxiety? • This in one of the most common groups of psychiatric disorders. • One in four persons has diagnosable anxiety disorder. • The 12-month prevalence rate is 17.7%. • The prevalence of these disorders decreases with higher socioeconomic status. Lifetime Prevalence of Anxiety Disorder 35% 30% 25% 20% 15% 10% 5% 0% Men Women What is the biological basis of anxiety?1,2 • Autonomic Nervous System – • Neurotransmitters – – – • Some genetic component clearly contributes to the development of anxiety disorders. Neuroanatomical Considerations – – – 1 Some patients with anxiety disorders have functional or anatomical changes. Genetic Studies – • Norepinephrine Serotonin γ- aminobutyric acid (GABA) Brain-Imaging Studies – • Increased sympathetic tone in anxious patients The locus ceruleus and raphe nuclei project to the limbic system. The limbic system contains a high concentration of GABAA receptors. The frontal cerebral cortex is connected with the parahippocampal region, the cingulate gyrus, and the hypothalamus. Kaplan & Sadock, 2008 observations are true for all of the anxiety disorders. 2These What about Anxiety Disorder Due to Another Medical Condition? • Anxiety commonly accompanies many different general medical conditions. • These underlying conditions cause anxiety via the noradrenergic and perhaps the serotonergic systems. • Paroxysmal bouts of anxiety should make clinicians suspicious. • The clinical features can be identical to those of the primary anxiety disorders. 1 If youtremors decide up that the Most arefront worsened by patient anxiety.is • Primary anxiety disorders generally have their onset before age 35. • Anxiety symptoms may persist after the primary disorder is treated. • The underlying disorder should be treated first, but the anxiety may need to be addressed separately.1,2 a crock, this will set you up for some serious mistakes. significant with the history conduction of a dilated disturbance. pupil. 3 I unexpectedly experienced panic when undergoing MR imaging. 2 One I admitted of my “crock” a man from patients the ED presented who developed to the ED a What about Substance/MedicationInduced Anxiety Disorder? • • • • • • This is a common consequence of recreational and prescription drug abuse. You must think about it and ask about it every time. Don’t forget about caffeine. The associated clinical features may vary with the substance involved.1,2 Cognitive impairments in comprehension, calculation and memory usually disappear when the • substance is discontinued. 1 Most tremors are aworsened by People who take lot of speed The differential diagnosis includes – Primary anxiety disorders – Anxiety due a general medical condition (for which the patient may be receiving the implicated drug) – Mood disorders – Personality disorders – Malingering Removal of the offending substance is the preferred treatment anxiety. become overtly paranoid. admitted a man from the ED who a significant disturbance. evaluated a patient at a MHC whodeveloped was convinced that theconduction FBI was landing UFOs in his backyard. 3 I unexpectedly experienced panic when undergoing MR imaging. 2I What about patients who present with mild mixed anxiety and depression? • These are patients that don’t meet full criteria for either a mood or an anxiety disorder. • They are particularly common in primary care practices. • On careful examination, they often are depressed; the accompanying anxiety is misleading. • This controversial presentation is not a separate diagnosis. • This combination of symptoms leads to considerable functional impairment. • Up to 2/3 of depressed persons are also anxious and up to 9/10 of panic patients experience depression. • If this emerges as a specific diagnosis, it may affect about 1% of the population. • The serotonergic drugs are helpful for both the anxiety and depression.1,2,3 1 These Most tremors “mixed are syndromes” worsenedcan by be anxiety. very challenging. 2 When I admitted in doubt, a man treat from forthe depression. ED who developed It is very ahard significant to get patients conduction off benzodiazepines. disturbance. 3A I unexpectedly number of these experienced patients will panic report when definite undergoing benefit MR from imaging. one of the SSRIs. What treatment options are available? • Medication • Non-medication • Antidepressants interventions • Benzodiazepines • No treatment • Atypical antipsychotics • Distractions • Buspirone (Buspar) • Sensory override strategies • Antihistamines • Meditation • Progressive relaxation exercises • Cognitive behavioral therapy 1 Most tremors are worsened by anxiety. admitted a man from the ED who developed a significant conduction disturbance. 3 I unexpectedly experienced panic when undergoing MR imaging. 2I What practical guidelines should you follow when prescribing medication for anxiety? • Make the correct diagnosis first; the treatment differs. • Fix the problem that is causing the anxiety if you can. • Try every reasonable nonmedical intervention first unless the severity of the symptoms will not allow that. • The SSRIs and SNRIs are currently considered the medications of first choice for most anxiety disorders. • If you need to block panic attacks immediately, clonazepam (Klonopin) is the go-to drug. 1 Most • Use benzodiazepines for only a brief period of time before tapering—if possible. • Encourage exposure and cognitive therapy from the start; pills are rarely the answer by themselves. • Support your patients in their management of their chronic illnesses. • Use the atypical antipsychotic medications and anticonvulsants for anxiety ONLY as a last resort and after a psychiatric consultation. tremors are worsened by anxiety. admitted a man from the ED who developed a significant conduction disturbance. 3 I unexpectedly experienced panic when undergoing MR imaging. 2I What problems will you face when prescribing antidepressants? Problem Solution Your anxious patients may become even more anxious after starting the drug. Lower the starting dosage, reassure them and counsel patience. Your patients may complain of unpleasant side effects. If possible, recommend persistence and completion of an adequate trial. Your patients may need immediate blockage of panic attacks. Don’t hesitate to add clonazepam (Klonopin) and taper it later. Your patients may want to try the same Agree to try it. This is a very good idea. drug a family member took with benefit. Your patients may not want to take ANY medication long term. 1 Most The rare PRN use of benzodiazepines makes some sense. PRN SSRIs do not. tremors are worsened by anxiety. admitted a man from the ED who developed a significant conduction disturbance. 3 I unexpectedly experienced panic when undergoing MR imaging. 2I What problems might you face when prescribing benzodiazepines? Problem Solution You may not be comfortable prescribing benzodiazepines at all. Refer the patient to a more flexible, mature and experienced provider. You may not feel comfortable prescribing benzodiazepines long-term. Seek a consultation from a psychiatrist. Your patient may insist that you prescribe when you don’t agree. Refer to a colleague BEFORE anyone gets mad. You may discover that your patient is abusing your medication. Confront them respectfully, then taper and discontinue the medication. You may need to taper the medication. Warn about relapse, rebound, withdrawal and taper slowly. tremorsconclude are worsenedthat by anxiety. You may the benefits of Document your unsuccessful attempts I admitted a man from the ED who developed a significant conduction disturbance. I unexpectedlyuse experienced panic when long-term outweigh theundergoing risks. MR imaging.to taper and monitor carefully. 1 Most 2 3 The Psychiatric Interview A Patient-Centered, Evidence-Based Diagnostic and Treatment Process • • • • • • • • • • Introduce yourself using AIDET1. Sit down. Make me comfortable by asking some routine demographic questions. Ask me to list all of my problems and concerns. Using my problem list as a guide, ask me clarifying questions about my current illness(es). Using evidence-based diagnostic criteria, make accurate preliminary diagnoses. Ask about my past psychiatric history. Ask about my family and social histories. Clarify my pertinent medical history. Perform an appropriate mental status examination. • • • • • • • • • • Review my laboratory data and other available records. Tell me what diagnoses you have made. Reassure me. Outline your recommended treatment plan while making sure that I understand. Repeatedly invite my clarifying questions. Be patient with me. Provide me with the appropriate educational resources. Invite me to call you with any additional questions I may have. Make a follow up appointment. Communicate with my other physicians. Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them. 1 How can you access the OU-HCOM psychiatry flash cards online? • Go to Quizlet. • Create a free account. • When you receive a confirmatory email, click on the link to activate your new account. • With your activated account open in another browser window, click on this link to join the class. • You can download the free Quizlet app to your iPhone or import these learning sets to the more robust Flashcards Deluxe app. • Enjoy. I hope you find these cards helpful. • Please post your feedback or suggestions on the Quizlet site. Where can you learn more? • • • • • • • • • American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2013 Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008 Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here. Flaherty, AH, and Rost, NS, The Massachusetts General Hospital Handbook of Neurology, 2011 Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Third Edition, 2011 Klamen, D, and Pan, P, Psychiatry PreTest Self-Assessment and Review, Thirteenth Edition, 2012 Blitzstein, Sean, Lange Q&A Psychiatry, 2011 Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, 2008 Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, 2010 Where can you find evidence-based information about mental disorders? • • • • Explore the site maintained by the organization where evidence-based medicine began at McMaster University here. Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here. Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here. Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here. How can you contact me? Kendall L. Stewart, MD, MBA, DLFAPA VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 [email protected] [email protected] www.somc.org www.KendallLStewartMD.com Are there other questions?1,2 Justin Greenlee, DO Director Family Medicine Residency Safety Quality Service Relationships Performance Thomas Carter, DO Director Emergency Medicine Residency 1Learn 2Learn more about Southern Ohio Medical Center. more about our Family Medicine and Emergency Medicine Residencies.