Anxiety - Palmetto Lowcountry Behavioral Health

Report
ECPSLLC.COM
•O (843) 856 6998
•F (843) 856 6997
Anxiety Spectrum Updates 2012
Ricardo J. Fermo, MD
Medical Director
East Cooper Psychiatric Solutions, LLC
1073 B. Johnnie Dodds Blvd.
Mount Pleasant, South Carolina 29464
Diplomate of the American Board of Psychiatry and
Neurology
Diplomate of American Board of Child and Adolescent
Psychiatry
FINANCIAL DISCLOSURES/CONFLICTS
OF INTEREST
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Abbott Laboratories
AstraZeneca
Bristol Myer-Squibb
Cephalon
Eli Lilly & Co.
Forest Laboratories, Inc.
GalaxoSmithKline
Janssen Research
Jazz Pharmaceuticals
Mallinckrodt
Merck
Novartis
Palmlabs
Pfizer, Inc.
Sanofi Aventis
Sepacor Inc.
Shire Pharmaceuticals
Somaxon Pharmaceuticals
Sunovion Pharmaceuticals Inc.
Takeda
UCB Pharma Inc.
Wyeth Pharmaceuticals
ECPSLLC.COM
Learning Objectives
• Review updates on the epidemiology of
Anxiety
• Provide a summary of the disease state (s)
• Discuss diagnostic criteria for various anxiety
disorders
• Treatment/Goals
– Discuss evidence-based approaches for
treatment-Anxiety
ECPSLLC.COM
References
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NIMH
SAMHCA
APA
CDC
CLINICALTRIALS.GOV
CLINICAL PRACTICE
EVIDENCE BASED MEDICINE WEBSITES
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GOOGLE SCHOLAR
COCHRANE
PUBMED
DYNAMED
EVIDENCE BASED (BMJ)
• www.adaa.org
• www.ocfoundation.org
• www.socialanxietysupport.com
• http://www.adaa.org/
• Stress and anxiety are the same thing.
•
True
•
False
• The causes of stress are essentially the same
for everyone.
•
True
•
False
• Anxiety is the most common mental illness in
the US:
– True
– False
• Men are twice as likely to have Generalized
Anxiety then Woman?
» True
» False
• What percentage of people with mental
illnesses improve if they receive treatment?
•
25% to 45%
•
50% to 70%
•
70% to 90%
Anxiety as a Normal
and an Abnormal Response
• Some amount of anxiety is “normal” and is
associated with optimal levels of functioning.
• Only when anxiety begins to interfere with
social or occupational functioning is it
considered “abnormal.”
ANXIETY DISORDERS
• Anxiety is a normal reaction to stress and can
actually be beneficial in some situations.
• Fear and anxiety are part of life
• anxiety can become excessive, and while the
person suffering may realize it is excessive they
may also have difficulty controlling it and it may
negatively affect their day-to-day living.
• Most common of emotional disorders
• Affects more than 40 million Americans
• The most prevalent psychiatric disorders
The Fear and Anxiety Response
Patterns
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Fear
Panic
Anxiety
Anxiety Disorder
Definition of Anxiety
• Anxiety is a feeling of apprehension or fear. The
source of this uneasiness is not always known or
recognized, which can add to the distress you feel.
• Anxiety disorders are a group of psychiatric
conditions that involve excessive anxiety.
Anxiety Facts
• Anxiety disorders are the most common mental illness in
the U.S., affecting 40 million adults in the United States age
18 and older (18% of U.S. population).
• Anxiety disorders are highly treatable, yet only about onethird of those suffering receive treatment.
• Anxiety disorders cost the U.S. more than $42 billion a year,
almost one-third of the country's $148 billion total mental
health bill, according to "The Economic Burden of Anxiety
Disorders," a study commissioned by ADAA (The Journal of
Clinical Psychiatry, 60(7), July 1999).
• More than $22.84 billion of those costs are associated with
the repeated use of health care services; people with
anxiety disorders seek relief for symptoms that mimic
physical illnesses.
• Anxiety disorders in the U.S. cost more than
$42 billion each year.
• 1/3 of the total amount spent on mental
health care
Anxiety Disorders
• One-quarter of the U.S. population experiences pathologic anxiety in their
lifetime
• People with an anxiety disorder are three to five times more likely to go to
the doctor and six times more likely to be hospitalized for psychiatric
disorders than those who do not suffer from anxiety disorders.
• Anxiety disorders develop from a complex set of risk factors, including
genetics, brain chemistry, personality, and life events.
• Anxiety and Depression
• It's not uncommon for someone with an anxiety disorder to also suffer
from depression or vice versa. Nearly 70 % of those diagnosed with
depression are also diagnosed with an anxiety disorder.
• Presenting problem for 11% of patients visiting primary care physicians
• 90% of patients with anxiety present with somatic complaints
Anxiety
• Nervousness and fear are common human
emotions.
• Adaptive at lower levels; disabling at high
levels.
• Physicians must recognize the difference
between pathological anxiety and anxiety as a
normal or adaptive response.
Definition of Anxiety
• Diffuse, unpleasant, vague sense of apprehension
• Often accompanied by autonomic symptoms such as
headache, perspiration, heart palpitations, chest
tightness, stomach discomfort and restlessness
• Presentation depends on perception of stress,
personal resources, psychological defenses, and
coping mechanisms
Pathological Anxiety
• Anxiety that is excessive, persistent, easily
triggered.
• Degree of the person’s fear is out-of-proportion
to actual danger.
• Disrupts the person’s life and functioning.
• Creates intense discomfort.
• Doesn’t respond to rational reassurance.
• in pathological anxiety, attention is focused also
on the person's response to the threat.
Features of Pathologic Anxiety
• Autonomy: no or minimal environmental
trigger
• Intensity: exceeds patient’s capacity to bear
the discomfort
• Duration: symptoms are persistent
• Behavior: anxiety impairs coping and results in
disabling behaviors
Etiology
• Neurophysiology
– Central noradrenergic systems– in particular, the locus
coeruleus is the major source of adrenergic innervation
– GABA neurons from the limbic system
– Serotoninergic systems and neuropeptides
• Cognitive-Behavioral Formulations
• Developmental (Psychodynamic) Formulations
Common Medical Conditions Associated with
Anxiety Disorders
• Endocrine: thyroid
dysfunction, hyper
adrenalism
• Drug Intoxication:
caffeine, cocaine
• Drug Withdrawal:
alcohol, narcotics
• Hypoxia: CHF, angina,
anemia, COPD
• Metabolic: acidosis,
hyperthermia
• Neurological: seizures,
vestibular dysfxn
Lifetime Prevalence of
Common Psychiatric Disorders
Prevalence
17.1%
Major depressive disorder1
14.1%
Alcohol dependence1
13.3%
Social anxiety disorder1
Posttraumatic stress
disorder (PTSD)2
7.8%
Generalized anxiety
disorder (GAD)1
5.1%
3.5%
Panic disorder1
Obsessive-compulsive
disorder (OCD)3
2.5%
0
*In menstruating women.
2
4
6
8
10
12
14
16
18
Prevalence (%)
Kessler RC, et al. Arch Gen Psychiatry. 1994;51(1):8-19.1 Kessler RC, et al. Arch Gen Psychiatry. 1995;52(12):1048-1060.2 DSM-IV-TR 2000.3
29 of 45
• 40 million American adults age 18 years and
older (about 18%)
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Generalized Anxiety Disorder
Obsessive-Compulsive Disorder (OCD)
Panic Disorder
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (or Social Anxiety Disorder)
Specific Phobia
• Each anxiety disorder has different symptoms,
but all the symptoms cluster around excessive,
irrational fear and dread.
Explaining anxiety disorders
• Learning perspective
• Biological perspective
Learning perspective
• Fear conditioning
– One bad event can lead to classical conditioning of
fear
• Stimulus generalization
– Fear may broaden: fear of heights fear of
airplanes
Learning perspective
• Reinforcement can help maintain fears.
– Avoiding or escaping the feared situation reduces
anxiety, so the avoiding or escaping behavior is
reinforced
Learning perspective
• Observational learning
– We learn our fears by watching and listening to
others
Biological perspective
• We are biologically prepared to fear threats
faced by ancestors
– Spiders
– Snakes
– Darkness
Biological perspective
• Genes
– Some people seem genetically predisposed to
particular fears and high anxiety
Biological perspective
• 35 year old identical twins who independently
developed claustrophobia and fear of water
Biological perspective
• Physiology
– Brain scans of people with OCD  unusually high
activity in certain parts of the frontal lobes
• Physiology
– Generalized anxiety, panic attacks, and
OCD are linked with overarousal in
brain areas linked with impulse control
and habitual behaviors
– People cannot “turn off” these
thoughts.
Physical Reaction to Anxiety
Auditory and Visual Stimuli:
sights and sounds are processed
first by the thalamus, which filters
the incoming cues and shunts
them either directly to the
amygdala or to the other parts of
the cortex.
Olfactory and tactile stimuli:
Smells and touch sensations
Bypass the thalamus altogether,
Taking a shortcut directly to the
Amygdala. Smells, therefore,
Often evoke stronger memories
Or feelings than do sights or
Sounds.
Physical Reaction to Anxiety
Thalamus:
The hub for sights and sounds,
The thalamus breaks down
Incoming visual ques by size,
Shape and color, and auditory
Cues, by volume and
Dissonance, and then signals
The appropriate part of the
Cortex.
Cortex:
It gives raw sights and sounds
meanings, enabling the brain
to become conscious of what it
Is seeing or hearing. One
region, the prefrontal cortex,
may be vital to turning off the
anxiety response once a threat
has passed.
Physical Reaction to Anxiety
Amygdala:
emotional core of the brain, the
amygdala has the primary role
of triggering the fear response.
information that passes through
the amygdala is tagged with
emotional significance.
Bed Nucleus of Stria Terminalis:
unlike the Amygdala, which sets off
an immediate burst of fear, the
BNST perpetuates the fear
response, causing the longer term
unease typical of
anxiety.
Physical Reaction to Anxiety
Locus Ceruleus:
It receives signals from the
amygdala and is responsible
for initiating many of the
classic anxiety responses:
rapid heartbeat, increased
blood pressure, sweating and
pupil dilation.
Hippocampus:
This is the memory center,
vital to storing the raw
information coming in from
the senses along with the
emotional baggage attached
to the data during their trip
through the amygdala.
Generalized Anxiety Disorder:
Biological Causal Factors
• Genetic factors
• A functional deficiency of GABA
• Neurobiological differences between
anxiety and panic
Relationship Between Arousal (anxiety) and
Performance
Yerkes-Dodson Law
Three Components of Anxiety
• Physical
• Psychological (Cognition and emotion)
• Behaviours
The Physical Component
 Trembling, twitching ,Shaking
 Dizziness
 Numbness/Tingling
 Backache, headache
 Muscle tension
 Shortness of breath, hyperventilation
 Fatigability
 Startle response
 Difficulty swallowing
Autonomic hyperactivity:
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Flushing and pallor
Tachycardia, palpitation
Sweating
Cold hands
Diarrhea
Dry mouth (xerostomia)
Urinary frequency
Blurred Vision
The Psychological Component
Anxious Thoughts
Anxious Predictions
Anxious Beliefs and Interpretations
Difficulty in Attention and Memory
Mental Images
Unreality/Detachment
Hypervigilance
Insomnia
Decreased libido
Lump in the throat
The Behavioural Component
Avoidance of Situations and Activities
Subtle Avoidance Strategies, Safety Signals,
and Overprotective Behaviours
Alcohol, Drug, and Medication Use
Anxiety Disorders - DSM-IV
1. Generalized Anxiety
Disorder (GAD)
2. Panic Disorder (PD)
with Agoraphobia (AG)
7. Post traumatic Stress
Disorder (PTSD)
8. Acute Stress Disorder
(ASD)
3. PD without Agoraphobia 9. Substance-Induced
4. Specific Phobia (SP)
5. Social Phobia (SoP)
6. Obsessive Compulsive
Disorder (OCD)
Anxiety disorder (SIAD)
10. Anxiety disorder due
some medical illness
Dual Diagnosis Disorders
Anxiety disorders
Continuous anxiety
Episodic anxiety
Generalized anxiety disorder
In defined situation
Phobic anxiety disorder
Simple
phobia
Social
phobia
Mixed pattern
Panic disorder with
agoraphobia
Agoraphobia
In any situation
Panic disorder
Epidemiology
• Overall, anxiety disorders are among the most
prevalent of psychiatric disorders.
• Age; Earlier onset than depression
• Sex factor; More in females
• Frequency (Prevalence):
18 %of general population
28% (life time prevalence)
• Strong genetic component
Shared features of anxiety disorders
• Substantial proportion of aetiology is stress related.
• Difference with Psychosis
- free of delusions and hallucinations, good insight
- Reality testing is intact.
• Symptoms are ego dystonic (distressing)
• Disorders are enduring or recurrent.
• Demonstrable organic factors are absent
• Note: Hierarchy of Diagnosis Precedence:
Psychosis >Depression >Anxiety
Risk Factors/Etiology
 Psychodynamic theory posits that anxiety occurs when instinctual
drives arc thwarted (dissatisfied).
 Behavioral theory states that anxiety is a conditioned response to
environmental stimuli originally paired with a feared situation.
 Cognitive approach: Selective attention and catastrophic thinking
 Biologic theories implicate various neurotransmitters (especially:
gamma-aminobutyric acid [GABA], norepinephrine, and serotonin)
and various CNS structures (especially reticular activating system
and limbic system).
 Other theories: Social and personality factors.
The Psychodynamic Approach to Anxiety
• Anxiety is a signal that the ego is having a hard time mediating
between reality, id and superego.
• Different anxiety disorders are the result of different defense
mechanisms used to cope.
– Phobia - displacement
– OCD - reaction formation, undoing
– PTSD - denial, repression
• Attachment Theories : Bowlby
– disturbances in parent-child bond leads to “anxious
attachment” and a vulnerability to anxiety disorders later in
life.
The Behavioural Approach to Anxiety
(learning theory)
 Behavioral theories:- anxiety is a conditional response to
specific environmental stimuli followed by its generalization,
displacement, or transference.
 It may be learned through identification and imitation of anxiety
pattern in parents (social learning theory).
 Mowrer (1948) Avoidance learning (learned behaviour)
1) classical (respondent) conditioning
2) negative reinforcement
The Cognitive Approach to Anxiety
•
Individuals misperceive and misinterpret internal and external stimuli.
 Selective attention and catastrophic thinking
 Cognitive Appraisal (perceive threat)
 Stimulus--->Appraisal---> Response
 evaluation of stimulus based on memories, beliefs, and expectations.
. Albert Ellis identified basic irrational assumptions:
• It is necessary for humans to be loved by everyone
• It is catastrophic when things are not as one wants them to be
• If something is dangerous, a person should be terribly concerned and
dwell on the possibility that it will occur
• One should be competent in all domains to be a worthwhile person
The idea is, when these assumptions are applied to everyday life, GAD may
develop.
• Aaron Beck :Those with GAD hold unrealistic silent assumptions that imply
imminent danger:
• Any strange situation is dangerous
• A situation/person is unsafe until proven safe
The Biological Approach to Anxiety
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Genetic Component
 family and twin studies suggest a genetic component in most anxiety disorders
 panic disorder shows the strongest genetic component and generalized anxiety
disorder the least.
 Neurotransmitter abnormalities
- the release of catecholamine (NA, DA) is increased.
- decrease level of GABA (GABA inhibit CNS irritability).
- serotonin decrease causes anxiety; increased dopaminergic activity is associated
with anxiety.
 Activity in the temporal cerebral cortex is increased.
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The locus ceruleus, a brain center of noradrengic neurons, is hyperactive in anxiety
disorders, especially panic attacks.
Elevated responsiveness in the amygdala, part of the fear circuit of the limbic system.
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HPA axis dysregulation
Serotonin and basal ganglia abnormalities in OCD
Hormonal theory of PTSD
Other theories:
• Social factors
– Early life adversity
– Stressful events especially those involving threat
– Lack of support network
• Personality factors
– Some personality traits predispose to certain
anxiety disorders – avoidant, perfectionist
Depression-Anxiety Comorbidity
The lifetime prevalence of depression
is 60% in patients with social anxiety
disorder
The lifetime
prevalence of
depression is 57% in
patients with panic
disorder
Anxiety
Disorders
24.9%
(lifetime
prevalence)
Up to 60%
Overlap
Brown TA, et al. J Abnorm Psychol 2001;36:578-584.
Kessler RC, et al. JAMA 2003;289:3095-3105.
Kessler RC, et al. Arch Gen Psychiatry 1994;51:8-19.
Major
Depressive
Disorder
16.2%
(lifetime
prevalence)
Depression and Anxiety Disorders Commonly
Occur Together
SAD
37%*
Fear/avoidance
of social situations
Blushing
Trembling/shaking
GAD
62%*
(GAD + MDD1)
(SAD + MDD2)
Low selfPalpitations
Difficulty
Sweating concentrating esteem
GI complaints
Interpersonal
Anhedonia
Worry
sensitivity
Depressed mood
Anxiety
Suicidal ideation
Agitation
Muscle tension
Irritability
Feelings of
worthlessness
Dry mouth
Sleep disturbance
Fatigue
Appetite
disturbance
Pain
MDD
*Lifetime prevalence of MDD among individuals with lifetime diagnoses of each anxiety disorder.
1. Wittchen HU, et al. Arch Gen Psychiatry. 1994;51:355-364.
2. Magee WJ, et al. Arch Gen Psychiatry. 1996;53:159-168.
3. DSM-IV-TR™. Washington, DC: American Psychiatric Association; 2000.
Screening and Diagnosis
Measurement-Based Care
• Screening
– GAD-7, LSAS, PTSD, YBOC
– Detect depression (PHQ-9, QIDS, CUDOS, Zung)
– Rule out bipolarity (MDQ, WHO CIDI 3.0)
• Diagnosis
– DSM-IV overview
– Comorbidity
• Suicide Assessment
• Symptom Tracking
– HAM-A (physician)
– CGI-A
generalized anxiety disorder
(GAD)
Generalized Anxiety Disorder
• Excessive uncontrollable worry about everyday
things. This constant worry affects daily
functioning and can cause physical symptoms.
• GAD can occur with other anxiety disorders,
depressive disorders, or substance abuse.
Generalized Anxiety Disorder
• The focus of GAD worry can shift, usually
focusing on issues like job, finances, health of
both self and family; but it can also include
more mundane issues such as, chores, car
repairs and being late for appointments.
• The intensity, duration and frequency of the
worry are disproportionate to the issue
Generalized Anxiety Disorder
• Characterized by at least 6 months of
persistent and excessive anxiety and worry
GAD Epidemiology
• 5% prevalence in community samples
• 2:1 female/male ratio
• Age of onset is frequently in childhood or
adolescence
• Chronic but fluctuating course of illness
(worsened during stressful periods)
Generalized Anxiety Disorder (GAD)
• Patients with GAD suffer from severe worry or
anxiety that is out of proportion to situational
factors.
• Must last most days for at least 6 months
• Described as “worriers” or “nervous”
GAD
• Symptoms include:
– Muscle tension
– Restlessness
– Insomnia
– Difficulty concentrating
– Easy fatigability
– Irritability
– Persistent anxiety (rather than discrete panic
attacks)
GAD Diagnostic Criteria
• Excessive anxiety and worry that occurs more
days than not for 6 months
• Difficult to control the worry
• 3 out of 6 symptoms
• Anxiety caused significant distress or
impairment in function
• Not attributed to another organic cause
GAD Treatment
• Cognitive Behavioral Therapy
• Other Psychotherapies
• Pharmacotherapy
– Antidepressants
– Benzodiazepines
– Buspirone
Common Causes
• There is no one cause for anxiety disorders. Several factors can
play a role
– Genetics
– Brain biochemistry
– Overactive "fight or flight" response
• Can be caused by too much stress
– Life circumstances
– Personality
• People who have low self-esteem and poor coping skills may be more prone
• Certain drugs, both recreational and medicinal, can lead to
symptoms of anxiety due to either side effects or withdrawal
from the drug.
• In very rare cases, a tumor of the adrenal gland
(pheochromocytoma) may be the cause of anxiety.
Symptoms of Anxiety
Anxiety is an emotion often accompanied by
various physical symptoms, including:
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Twitching or trembling
Muscle tension
Headaches
Sweating
Dry mouth
Difficulty swallowing
Abdominal pain (may be the only symptom of stress
especially in a child)
Additional Symptoms of Anxiety
Sometimes other symptoms accompany
anxiety:
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Dizziness
Rapid or irregular heart rate
Rapid breathing
Diarrhea or frequent need to urinate
Fatigue
Irritability, including loss of your temper
Sleeping difficulties and nightmares
Decreased concentration
Sexual problems
Generalized anxiety disorder
• Person is continually tense, apprehensive, and
in a state of CNS arousal.
Generalized anxiety disorder
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Tense and jittery
Worried bad things will happen
Muscular tension
Agitation
Sleeplessness
Generalized anxiety disorder
• Person cannot identify the cause of the
anxiety, and therefore can’t avoid or deal
• “Free floating anxiety”
Generalized anxiety disorder
• Worry about things that are not too likely to
happen
• Worry more intensely
Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is characterized by
unrealistic or excessive worry (generalized free-floating
persistent anxiety) about every day events/problems with
symptoms of muscle and psychic tension, causing significant
distress/functional impairment.
What is Gen. Anxiety Disorder ?
 Anxiety Disorders are characterized by
persistent fear and anxiety that occurs too
often, is too severe, is triggered too easily or
lasts too long.
 Compared with others with anxiety disorders,
persons with GAD have a better ability to
maintain normal work and social relationships in
spite of their distress.
 The “What if?” disorder
DSM-IV Diagnostic Criteria for Generalized Anxiety Disorder
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A. Excessive anxiety or worry is present most days during at least a six-month
period and involves a number of life events.
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B. The anxiety is difficult to control.
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C. At least three of the following:
1. Restlessness or feeling on edge.
2. Easy fatigability.
3. Difficulty concentrating.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance.
•
D. The focus of anxiety is not anticipatory anxiety about having a panic attack, as
in panic disorder.
E. The anxiety or physical symptoms cause significant distress or impairment in
functioning.
F. Symptoms are not caused by substance use or a medical condition, and
symptoms are not related to a mood or psychotic disorder.
•
•
Diagnostic criteria of GAD- SUMMARY
Excessive Worry About
Work
Family and Children
Health
Finances
Minor Matters
Worry occurs most days (for at least 6 months)
Difficult to control worry
Associated with disturbed sleep, irritability,
restlessness, poor concentration, fatigue, muscle
tension
Clinical Features of Generalized Anxiety Disorder
• A. Other features often include insomnia, irritability, trembling,
muscle aches and soreness, muscle twitches, sweaty hands, dry
mouth, and a heightened startle reflex. Patients may also report
palpitations, dizziness, difficulty breathing, urinary frequency,
dysphagia, light-headedness, abdominal pain, and diarrhea.
• B. Patients often complain that they “can't stop worrying,” which
may revolve around valid concerns about money, jobs, marriage,
health, and the safety of children.
• C. Chronic worry is a prominent feature of generalized anxiety
disorder, unlike the intermittent terror that characterizes panic
disorder.
• D. Mood disorders, substance- and stress-related disorders
(headaches, dyspepsia) commonly coexist with GAD.
Up to one-fourth of GAD patients develop panic disorder.
Excessive worry and somatic symptoms, including autonomic
hyperactivity and hypervigilance, occur most days.
• E. About 30-50% of patients with anxiety disorders
will also meet criteria for major depressive disorder. Drugs and
alcohol may cause anxiety or may be an attempt at self-treatment.
Substance abuse may be a complication of GAD.
Differential Diagnosis of Generalized Anxiety
Disorder
A. Substance-Induced Anxiety Disorder:
Substances such as caffeine, amphetamines, or cocaine can cause anxiety symptoms.
Alcohol or benzodiazepine withdrawal can mimic symptoms of GAD.
These disorders should be excluded by history and toxicology screen.
B. Panic Disorder, Obsessive-Compulsive Disorder, Social Phobia,
Hypochondriasis and Anorexia Nervosa
1. Many psychiatric disorders present with marked anxiety, and the diagnosis of GAD
should be made only if the anxiety is unrelated to the other disorders.
2. For example, GAD should not be diagnosed in panic disorder if the patient has
excessive anxiety about having a panic attack, or if an anorexic patient has anxiety
about weight gain.
C. Anxiety Disorder Due to a General Medical Condition.
Hyperthyroidism, cardiac arrhythmias, pulmonary embolism,
congestive heart failure, and hypoglycemia, may produce
significant anxiety and should be ruled out as clinically indicated.
D. Mood and Psychotic Disorders
1. Excessive worry and anxiety occurs in many mood and psychotic
disorders.
2. If anxiety occurs only during the course of the mood or psychotic
disorder, then GAD cannot be diagnosed.
Course and prognosis
• Course is chronic; symptoms may diminish as
the patient get older.
• With time, secondary depression may develop.
This is not uncommon if the condition is left
untreated.
Treatment of Generalized Anxiety Disorder
The combination of
pharmacologic therapy and psychotherapy
is the most successful form of treatment.
I. Pharmacotherapy of Generalized Anxiety Disorder:
,Fluoxetine
A. Antidepressants
1. SSRIs and Venlafaxine
a. The onset of action of antidepressants is much slower than the
benzodiazepines, but they have no addictive potential and may
be more effective.
An antidepressant is the agent of choice when depression
coexists with anxiety.
b. The side-effect profile for GAD patients is similar to that seen
with depressive disorders.
2. Tricyclic antidepressants
are also effective in treating GAD, but adverse effects limit
their use.
Treatment Options
• Antidepressant Medications
– Selective Serotonin Reuptake Inhibitors (SSRI)
– Serotonin and Norepinephrine Reuptake Inhibitors (SNRI)
– Norepinephrine-dopamine Reuptake Inhibitors
– Mixed Selective Serotonin Reuptake Inhibitors and Receptor Blockers
– Tricyclic Antidepressants (TCA)
– Monoamine Oxidase Inhibitors (MAOI)
• Nonpharmacological Therapy
– Psychotherapy
 Cognitive Behavioral Therapy (CBT)
 Interpersonal Therapy (IPT)
 Biofeedback?
 Exposure Response Treatment
 Trauma Focused CBT
 DBT
Alternative Treatments
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Acupuncture
Aromatherapy
Breathing Exercises
Exercise
Meditation
Nutrition and Diet Therapy
Vitamins
Self Love
Factors to Consider in Choosing an Medications for Anxiety
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Patient preference
Nature of prior response to medication
Relative efficacy and effectiveness
Safety, tolerability, and anticipated side effects
Co-occurring psychiatric or general medical
conditions
Potential drug interactions
Half-life
Cost
B. Buspirone
a. Buspirone is an effective treatment for
GAD. It lacks sedative effects. Tolerance
to the beneficial effects of buspirone does
not seem to develop. There is no
physiologic dependence or withdrawal
syndrome.
C. Benzodiazepines
• 1. Benzodiazepines can almost always relieve anxiety if given
in adequate doses, and they have no delayed onset of action.
• 2. Benzodiazepines have few side effects other than sedation.
Tolerance to their sedative effects develops but not to their
antianxiety properties.
• 3. Drug dependency becomes a clinical issue if the
benzodiazepine is used regularly for more than 2-3 weeks. A
withdrawal syndrome occurs in 70% of patients, characterized
by intense anxiety, tremulousness, dysphoria, sleep and
perceptual disturbances and appetite suppression.
• 4. Slow tapering of benzodiazepines is crucial (especially those
with short half-lives).
Comparison of Benzodiazepines
BZN
Sedation Anxiolytic Half life
Lipid solu
Dose
Diazepam
+++
+
20-80 h
High
5 mg od
Alprazolam
+
+++
6-20 h
Low
0.5 mg qid
Clonazapam
++
+++
22-50 h
Low
0.5 mg bid
Lorazepam
++
++
10-20 h
Med
1 mg tid
+
+
7-30 h
Med
15 mg bid
Chlordiazepx
II. Non-Drug Approaches to Anxiety
• 1. Patients should stop drinking coffee and other caffeinated beverages, and
avoid excessive alcohol consumption.
• 2. Patients should get adequate sleep, with the use of medication if
necessary. Moderate exercise each day may help reduce the intensity of
anxiety symptoms.
• 3. Psychotherapy
• a. Cognitive behavioral therapy, with emphasis
on relaxation techniques and instruction on misinterpretation of physiologic
symptoms, may improve functioning in mild cases.
• b. Supportive or insight oriented psychotherapy can be helpful in mild cases
of anxiety.
GOOD SLEEP HYGENE
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
No sleeping during the day (If you have to no longer than 30 mins)
Don’t lay in bed if not sleepy Get out of bed if unable to sleep
No milk during the evening
No caffeine
No Nicotine
No Alcohol
Warm baths, no showers
No exercising before going to bed but exercise in the morning
Sleep at the same time every night
Wake up at the same time every morning
Make sure bed and pillow is comfortable, primarily for sleep with appropriate room temp (Cool
about 60 degrees), noise free (some sleep better with white noise). Remember Cool, dark and
quiet)
Jot down all of your concerns and worries
Avoid “Over the counter” sleep aides
Don’t over sleep
Set your body clock (wake up to light)
Develop a bedtime routine
No TV in bed
ECPSLLC.COM
Other Psychological managements:
Education about nature of disorder
Progressive muscle relaxation
Structured problem solving
Graded exposure to difficult situations
Support (guidance, advice, development of coping
strategies)
Counselling
Stress management (relaxation, meditation, exercise
regimens that improve stress recovery)
Combination
• Maximize benefit by affecting multiple
neurotransmitters
• Could increase adherence and lower drop-out rates
• Could target side effects of first agent (eg,
insomnia, fatigue, sexual dysfunction)
Papakostas G. J Clin Psychiatry. 2009;70(S6):16-25.
social anxiety disorder
• Social Anxiety Disorder 15 million,
6.8% Equally common among men and
women, typically beginning around age
13. (According to a 2007 ADAA survey, 36% of
people with social anxiety disorder report
experiencing symptoms for 10 or more years
before seeking help.
• Comorbity exisits
Social Phobia
• General characteristics
Fear of being in social situations in
which one will be embarrassed or
humiliated
Social Phobia
• Interaction of psychosocial and biological
causal factors
– Genetic and temperamental factors
– Perceptions of uncontrollability
– Cognitive variables
Social phobias
• Shyness to the extreme
• Persistent, irrational fear linked to presence of
others
• Fear of being scrutinized or negatively
evaluated by others
Social phobias
• Person with social phobia may avoid
– Speaking
– Eating out
– Going to parties
– Anything in the presence of others
CONCERN
• Very Under diagnosed and Therefore
undertreated.
• Can cause severe impairment in social,
occupational and academic functioning
• Can Lead to Avoidant Behavior
DIAGNOSIS
• Fear or avoidance of social or performance
situations
• Situations avoided, or endured with anxiety
or distress
• Patients recognize symptoms as excessive
or unreasonable
• Very distressing or disabling
.
Feared/Avoided Situations
• Public speaking/performing
• Eating, drinking, writing, working while being
observed by others
• Social events
• Dating
• Meeting new people
• Being center of attention
• Using public bathroom
Common Somatic Complaints
Stuttering
Palpitations
Blushing
Sweating
Trembling
Shaking
Spectrum of Social Discomfort
Transient
Low interference
Low avoidance
Chronic
High interference
High avoidance
Shyness
Nongeneralized SAD
Generalized SAD
Avoidant
personality disorder
Treatment Goals
•
•
•
•
Eliminate anxiety/phobic avoidance
Eliminate functional disability
Treat associated comorbidities
Choose therapy that is tolerable for the long
term
Social Phobia: Treatment
• Antidepressants, SSRI’s and MAOI’s
• High potency benzodiazepines
• Low doses of beta blockers are helpful for
public speaking (if only an occasional event);
this alleviates the autonomic symptoms
• Psychotherapy-cognitive restructuring
Treatment
• Medication Management
• Psychotherapy
• Combined Medication Management and
Psychotherapy
• Practice Practice Practice!
Social Effects of Anxiety
• Depression
– Not as involved with family and friends the way you used
to be
– Lowered quality of relationships
– Low energy
– Lack of motivation to do the things you once looked
forward to doing
• Unable to convey the person that you are
• Fear and avoidance of situations where previous
attacks occurred
• http://www.socialanxietysupport.com/disorde
r/liebowitz/
Obsessive-Compulsive Disorder
• Obsessive-Compulsive Disorder (OCD) 2.2
million, 1.0% Equally common among men and
women. The median age of onset is 19, with 25
percent of cases occurring by age 14. One-third of
affected adults first experienced symptoms in
childhood.
• Hoarding is the compulsive purchasing, acquiring,
searching, and saving of items that have little or
no value.
•
Obsessive-Compulsive Disorder
Characterized by uncontrollable obsessions and compulsions
which the sufferer usually recognizes as being excessive or
unreasonable.
• Obsessions are recurring thoughts or impulses that are
intrusive or inappropriate and cause the sufferer anxiety:
– Thoughts about contamination, for example, when an individual fears
coming into contact with dirt, germs or "unclean" objects;
– Persistent doubts, for example, whether or not one has turned off the
iron or stove, locked the door or turned on the answering machine;
– Extreme need for orderliness;
– Aggressive impulses or thoughts, for example, being overcome with the
urge to yell 'fire' in a crowded theater
Obsessive-Compulsive Disorder
• Compulsions are repetitive behaviors or rituals performed by the OCD
sufferer, performance of these rituals neutralize the anxiety caused by
obsessive thoughts, relief is only temporary.
– Cleaning. Repeatedly washing their hands, showering, or constantly cleaning
their home;
– Checking. Individuals may check several or even hundreds of times to make sure
that stoves are turned off and doors are locked;
– Repeating. Some repeat a name, phrase or action over and over;
– Slowness. Some individuals may take an excessively slow and methodical
approach to daily activities, they may spend hours organizing and arranging
objects;
– Hoarding. Hoarders are unable to throw away useless items, such as old
newspapers, junk mail, even broken appliances
• In order for OCD to be diagnosed, the obsessions and/or compulsions must
take up a considerable amount of the sufferers time, at least one hour every
day, and interfere with normal routines .
Obsessive-Compulsive Disorder
• Obsessions- repetitive unwanted ideas that
the person recognizes are irrational
• Compulsions- repetitive, often ritualized
behavior whose behavior serves to diminish
anxiety caused by obsessions
Obsessive-Compulsive Disorder
•
•
•
•
Prevalence and age of onset
Characteristics of OCD
Types of compulsions
Comorbidity with other disorders
Common Examples of OCD
Common Obsessions:
Contamination fears of germs, dirt,
etc.
Imagining having harmed self or
others
Imagining losing control of
aggressive urges
Common
Compulsions:
Washing
Repeating
Checking
Intrusive sexual thoughts or urges
Touching
Excessive religious or moral doubt
Counting
Forbidden thoughts
Ordering/arranging
A need to have things "just so"
Hoarding or saving
A need to tell, ask, confess
Praying
OCD is not OCPD
• Obsessive-Compulsive Disorder is different
from obsessive compulsive personality
disorder (OCPD)
• OCPD: a pervasive pattern of preoccupation
with orderliness, perfectionism and control
that begins by early adulthood
Obsessive-Compulsive Disorder:
Psychosocial Causal Factors
•
•
•
•
Psychoanalytic viewpoint
Behavioral viewpoint
The role of memory
Attempting to suppress obsessive thoughts
Obsessive-Compulsive Disorder:
Biological Causal Factors
• Genetic influences
• Abnormalities in brain
function
• The role of serotonin
OCD Treatment
• Serotonin reuptake inhibitors
• Clomipramine, a serotonergic tricyclic
antidepressant
• Psychotherapy: exposure and response
prevention
Panic Disorder
Epidemiology of Panic Disorder
• Panic disorder has a lifetime prevalence of 1.53.5%
• 2:1 female/male ratio
• ? Of true gender difference versus men tend
to self-medicate with alcohol and are less
likely to seek treatment.
• Onset is late teens through third decade of
life.
Panic Disorder With and Without
Agoraphobia
•
•
•
•
Panic disorder
Panic versus anxiety
Agoraphobia
Agoraphobia without panic
Panic Disorder
•
•
•
•
Prevalence and age of onset
Comorbidity with other disorders
Biological causal factors
The role of Norepinephrine and
Serotonin
Panic Attack
•
•
•
•
Discrete episodes of intense anxiety
Sudden onset
Peak within 10 minutes
Associated with at least 4 of the 13 other
somatic or cognitive symptoms of autonomic
arousal
Panic Attack Symptoms
• Cardiac: palpitations, tachycardia, chest pain
or discomfort
• Pulmonary: shortness of breath, a feeling of
choking
• GI: nausea or abdominal distress
• Neurological: trembling and shaking,
dizziness, lightheadedness or faintness,
paresthesias
Panic Attack Symptoms
• Autonomic Arousal: sweating, chills or hot
flashes
• Psychological:
– Derealization (feeling of unreality)
– Depersonalization (feeling detached from oneself)
– Fear of losing control or going crazy
– Fear of dying
Panic Disorder
• A syndrome characterized by recurrent
unexpected panic attacks (at least 4 in one
month)
• Attacks are followed for at least one month
with:
– Concern about having another attack
– Worry about implications of the attack
– Behavior changes because of the attacks
Agoraphobia
• Complication of panic disorder
• Means “ fear of the market”
• Anxiety or avoidance of places or situations
from which escape might be difficult,
embarrassing, or help may be unavailable.
• Restricts daily activities
Agoraphobia
• Agoraphobia
– The patient may avoid crowds, restaurants,
highways, bridges, movie theaters etc.
– In its most severe form, the patient may become
dependent on companions to face situations
outside the home.
– Some individuals become homebound.
Differential Diagnosis of Panic Disorder
• Not due to another anxiety disorder
• Not due to effects of a general medical condition
–
–
–
–
–
–
Cardiovascular disease
Pulmonary disease
Neurological disease
Endocrine disease
Drug intoxication or withdrawal
Other (lupus, infections, heavy metal poisoning, uremia,
temporal arteritis)
Panic Disorder: Costs
• 200,000 normal coronary angiograms/yr in the U.S.
at a cost of 600 million dollars: 1/3 of these patients
have panic disorder
• ½ of patients referred for non-invasive testing for
atypical chest pain and who have normal tests have
panic disorder
• 1/3 patients undergoing work-up for vestibular
disorder with c/o dizziness have panic disorder
Panic Disorder: Comorbidity
• Panic disorder patients have an increased
personal and family history of other anxiety,
mood and substance abuse disorders.
• Major depression is a co-morbid diagnosis in
1/3 of cases presenting for treatment
• Untreated patients have high risk of suicide
Panic Disorder: Treatment
• About 80% of patients will respond to
treatment
• Antidepressant medications are effective
– Serotonin reuptake inhibitors (SSRI) are first line
therapy
– Tricyclic antidepressants (TCA) and monoamine
oxidase inhibitors (MAOI’s) are also used.
Panic Disorder: Treatment
• Sedative-Hypnotics: benzodiazepines are
ideally used in the short term before an
antidepressant has had time to work
• Cognitive Behavioral Therapy (CBT): helps
patients overcome a learned pattern of
catastrophically misinterpreting the physical
symptoms associated with panic attacks.
Panic Disorder
• The abrupt onset of an episode of intense fear or
discomfort, which peaks in approximately 10 minutes,
and includes at least four of the following symptoms:
•
•
•
•
•
•
A feeling of imminent danger or doom
The need to escape
Palpitations
Sweating
Trembling
Shortness of breath or a smothering
feeling
• A feeling of choking
• Chest pain or discomfort
• Nausea or abdominal discomfort
• Dizziness or lightheadedness
• A sense of things being unreal,
depersonalization
• A fear of losing control or "going crazy"
• A fear of dying
• Tingling sensations
• Chills or hot flushes
Panic Disorder
There are three types of Panic Attacks:
1. Unexpected - the attack "comes out of the blue" without
warning and for no discernable reason.
2. Situational - situations in which an individual always has an
attack, for example, upon entering a tunnel.
3. Situationally Predisposed - situations in which an individual is
likely to have a Panic Attack, but does not always have one. An
example of this would be an individual who sometimes has
attacks while driving.
Panic and the Brain
Panic Disorder
• Genetic factors
• Cognitive and behavioral causal factors
• Interoceptive fears
Panic Disorder: The Cognitive Theory
of Panic
Panic Disorder: The Cognitive Theory
of Panic
• Perceived control and safety
• Anxiety sensitivity as a vulnerability factor
for panic
• Safety behaviors and the persistence of
panic
• Cognitive biases and the maintenance of
panic
Treating Panic Disorder and
Agoraphobia
• Medications
• Behavioral and
cognitive-behavioral
treatments
Post-traumatic stress disorder
(PTSD)
Post Traumatic Stress Disorder (PTSD)
• Patients with PTSD have experienced a trauma
and develop disabling symptoms in response
to the event.
• Symptoms usually begin within 3 months of
the trauma
• Syndrome can occur at any age
Definition of Trauma
• The person experienced, witnessed or learned
of an event that involved actual or threatened
death, serious injury, or threat of harm to self
or others
• The person’s response involved intense fear,
helplessness or horror
Diagnosis of PTSD
• Symptoms must be > one month duration and
include:
– Re-experiencing symptoms
– Avoidance symptoms
– Emotional numbing
– Hyperarousal symptoms
Re-experiencing Symptoms
• There are recurrent, intrusive thoughts of the
event (can’t not think about it)
• Dreams (nightmares) about the event
• Acting or feeling the event is recurring, or
sense of living the event (flashbacks)
• Psychological or Physiological Distress upon
exposure to reminders or cues of the event.
Avoidance/Numbing Symptoms
• Avoid thoughts, feelings, places or people that
arouse memories of the event
• Being unable to recall important parts of the
event
• Decrease interest in activities
• Feeling detached or estranged from others
• Decreased range of affect
• Sense of foreshortened future
Hyperarousal Symptoms
• Patient experiences at least two of the
following:
– Insomnia (falling or staying asleep)
– Irritability or outbursts of anger
– Decreased concentration
– Hypervigilance
– Increased/exaggerated startle response
Post-Traumatic Stress Disorder
• Critical Component
– Symptoms occurs AFTER a traumatic stressor
Types of Traumas
• Natural
– earthquakes
– floods
– fires
• Human induces
– war
– crimes of violence
Types of Trauma
•
•
•
•
•
•
•
•
Sexual abuse
Rape
Physical abuse
Severe motor vehicle
accidents
Robbery/mugging
Terrorist attack
Combat veteran
Natural disasters
• Being diagnosed with a
life threatening illness
• Sudden unexpected
death of family/friend
• Witnessing violence
(including domestic
violence)
• Learning one’s child has
life threatening illness
Co-Morbid Diagnoses
• Alcoholism
– 75% for Vietnam Veterans with PTSD
• Depression
– 77% of firefighters with PTSD also have depression
• Generalized Anxiety
• Panic Attacks
Symptoms Categories
• Intrusive
– distressing recollections
– dreams
– flashbacks
– psychological trigger reactions
– physiological trigger reactions
Symptoms Categories
• Avoidance
– avoid thoughts, feelings or discussions
– avoid activities, places
– memory blocks
– anhedonia (without pleasure)
– numb
– alexithymia (emotions unknown)
– feeling of doom
Symptom Categories
• Hyperarousal Symptoms
– sleep disturbance
– anger problems
– concentration
– startle response
– “on guard” hypervigilence
Diagnoses
• Acute Stress Disorder
– new to DSM-IV (1994)
– symptoms 2 days to 4 weeks following traumatic
event
• PTSD
– new to DSM-III (1980)
– symptoms beyond 4 weeks
– delayed onset
Post-Traumatic Stress Disorder
• Exposure to traumas such as a serious accident, a natural
disaster, or criminal assault can result in PTSD. When the
aftermath of a traumatic experience interferes with normal
functioning, the person may be suffering from PTSD.
• Symptoms of PTSD are:
– Reexperiencing the event, which can take the form of intrusive thoughts and
recollections, or recurrent dreams;
– Avoidance behavior in which the sufferer avoids activities, situations,
people,and/or conversations which he/she associates with the trauma;
– A general numbness and loss of interest in surroundings;
– Hypersensitivity, including: inability to sleep, anxious feelings, overactive startle
response, hypervigilance, irritability and outbursts of anger.
Who Is Vulnerable?
• All ages
• Both genders
• Across Cultures and ethnic groups
PTSD Treatment
• Psychotherapies
– Exposure-based cognitive behavioral therapy
– Psychotherapy aimed at survivor anger, guilt and
helplessness (victimization)
• Pharmacological treatment targets the reduction of
prominent symptoms
– SSRI’s are first line therapy
– Atypical antipsychotics are being increasingly used
Specific Phobia
• Specific Phobias 19 million, 8.7% Women are
twice as likely to be affected as men.
• Related Illnesses Many people with an anxiety
disorder also have a co-occurring disorder or
physical illness, which can make their symptoms
worse and recovery more difficult. It’s essential to
be treated for both disorders.
Epidemiology of Specific Phobias
• Lifetime prevalence is 10% of the population
• Age of onset varies with subtype
– Childhood onset for phobias of animals, natural
environments blood and injections
– Bimodal distribution (childhood and mid-twenties
for situational phobias
Phobic Disorders
•
1.
2.
3.
Phobias
Specific phobias
Social phobia
Agoraphobia
Specific Phobias
Specific Phobias
• Psychosocial causal factors
• Genetic and temperamental causal factors
• Preparedness and the nonrandom
distribution of fears and phobias
• Treating specific phobias
Specific Phobia
• Marked and persistent fear that is excessive
and unreasonable of a specific object or
situation
• Exposure to the phobic stimulus will provoke
an anxiety response
Phobia Subtypes
•
•
•
•
•
Animals or insects
Natural environment– storms, water, heights
Blood, injury, injection, medical procedure
Situational flying, driving, enclosed places
Having a phobia of a specific subtype increased
the chances of having another phobia within that
subtype
Specific Phobia Treatments
• Flooding-exposing the person to the feared
stimulus
• Exposure therapy works to desensitize the
patient using a series of gradual, self-paced
exposures to the phobic stimulus; uses
relaxation, hypnosis, breathing control and
other cognitive approaches
• Benzodiazepines or Beta blockers are useful
acutely
Specific Phobia: Treatment
• Example: Fear of Flying
– Visualize a plane. Look at a plane in the sky. Drive
by an airport. Go to a museum that has planes.
Same museum—visualize going inside. Go inside.
Go to airport and watch planes take off and land.
Visualize yourself on a plane flying. Omnimax
theater experience. The real thing.
Treatment of Anxiety Disorders
•
•
•
•
Medications
Specific types of psychotherapy
Comorbidities
History
How to Get Help for Anxiety Disorders
•
•
•
•
•
See our MD
See A Clincian
Support Groups
CBT
Cut Caffiene, Alcohol, Drugs, Cold
Medicaations
• Internet
• Family Support Systems
Role of Research in Improving the Understanding and
Treatment of Anxiety Disorders
•
•
•
•
•
•
Role of Genes
Enviormental factors
Physical and psychological stress
Diet
Brain imaging technology
Neurochemical techniques – Amygdala and
Hippocampus
• Developing Medications and behavioral therapies
PSYCHIATRIC MANAGEMENT
•
•
•
•
•
•
•
•
•
•
Establish and maintain a therapeutic alliance
Complete the psychiatric assessment
Evaluate the safety of the patient
Establish the appropriate setting for treatment
Evaluate the functional impairment and quality of life
Coordinate the patient’s care with the other clinicians
Monitor the patient’s psychiatric status
Integrate measurements into psychiatric management
Enhance treatment adherence
Provide education to the patient and the family
ECPSLLC.COM
Monitor psychiatric status and safety.
• Monitor the patient for changes in destructive
impulses to self and
• others.
• Be vigilant in monitoring changes in psychiatric status,
including
• major depressive symptoms and symptoms of potential
comorbid
• conditions.
• Consider diagnostic reevaluation if symptoms change
significantly or
• if new symptoms emerge.
PE
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• History of the present illness and current symptoms
• Psychiatric history, including symptoms of mania
• Treatment history with current treatments and responses to previous
treatments
• General medical history
• History of substance use disorders
• Personal history (e.g., psychological development, response to
life transitions, major life events)
• Social, occupational, and family histories
• Review of the patient’s medications
• Review of systems
• Mental status examination
• Physical examination
• Diagnostic tests as indicated
Items to Monitor Throughout
Treatment
• Symptomatic status, including functional status,
and quality of life
• Degree of danger to self and others
• Signs of “switch” to mania
• Other mental disorders, including alcohol and
other substance use disorders
• General medical conditions
• Response to treatment
• Side effects of treatment
• Adherence to treatment plan
Selection of Treatment:
Make Your First Choice Count!
• Aim for remission of symptoms
– Choose agents with proven efficacy
– Use optimal dose
• Minimize dropout
– Consider efficacy/tolerability/safety profile
– Maximize adherence
• Prevent relapse/recurrence
– Achieve remission of symptoms!
– Adequate duration
American Psychiatric Association. Am J Psychiatry. 2000;157(4 suppl):1-45.
Summary and Take-Home Messages
• Patients can have a high rate of nonadherence
with SSRIs due to adverse events
• First few weeks of therapy are critical
• Monitor medication compliance during this time
period
• Choose a medication that is effective and
generally well tolerated across indications
Onset of Adverse Events and Efficacy
Therapeutic Effect
Adverse Events
Antidepressant
Therapy
Time
Adapted from American Psychiatric Association. Am J Psychiatry. 2000;157(Suppl 4):1-45.
Bull SA, et al. Ann Pharmacother. 2002;36:578-584.
Side effects of antidepressant
medications
1. Selective serotonin reuptake inhibitors
•
•
•
•
•
•
•
•
•
a. Gastrointestinal
b. Activation/insomnia
c. Sexual side effects
d. Neurological
e. Falls
f. Effects on weight
g. Serotonin syndrome
h. Drug interactions
i. Discontinuation syndrome
Side effects of antidepressant
medications
2. Serotonin norepinephrine reuptake inhibitors
Venlafaxine, Desvenlafaxine, Duloxitine
Nausea
Dry mouth
Sweating
Agitation
Sedation
Weight
Sexual Dysfunction
Elevated Blood Pressure
Side effects of antidepressant
medications
• 4. Tricyclic antidepressants
– a. Cardiovascular effects
– b. Anticholinergic side effects
– c. Sedation
– d. Weight gain
– e. Neurological effects
– f. Falls .
– g. Medication interactions
Side effects of antidepressant
medications
• 5. Monoamine oxidase inhibitors
– a. Hypertensive crises
– b. Serotonin syndrome
– c. Cardiovascular effects
– d. Weight gain
– e. Sexual side effects
– f. Neurological effects
Buspar
• Nausea
• Dizziness
Psychotherapy .
• Specific psychotherapies
– Cognitive and behavioral therapies
– Interpersonal psychotherapy
– Psychodynamic psychotherapy
– Problem-solving therapy
– Marital therapy and family therapy
– Group therapy
• Implementation
• Combining psychotherapy and medication
Complementary and alternative
treatments
•
•
•
•
•
•
•
a. St. John’s wort
b. S-adenosyl methionine
c. Omega-3 fatty acids
d. Folate
e. N-Acetyl Cysteine
f. Acupuncture
G. Yoga
Assessing response and
adequacy of treatment
Potential Reasons for Treatment
Nonresponse
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Inaccurate diagnosis
Unaddressed co-occurring medical or psychiatric
disorders, including substance use disorders
Inappropriate selection of therapeutic modalities
Inadequate dose of medication or frequency of
psychotherapy
Pharmacokinetic/pharmacodynamic factors affecting
medication action
Inadequate duration of treatment
Nonadherence to treatment
Persistent or poorly tolerated side effects
Complicating psychosocial and psychological factors
Inadequately trained therapist or poor “fit” between
patient and therapist
Treatment Should Be
Discontinued Gradually
•
•
•
•
Most antidepressants need to be tapered
Gradually taper dose (1 dosage level per week)1
Longer-term treatment may require slower taper1,2
Discontinuation symptoms are possible soon after stopping
drugs with short half-lives1,2
• Counsel patients on possible discontinuation symptoms,
including:
– Agitation, anorexia, diarrhea, dizziness, dry mouth, insomnia, nausea,
nervousness, sensory disturbances, somnolence, and sweating1
1. EFFEXOR XR® (venlafaxine HCl) Prescribing Information.
2. American Psychiatric Association. Am J Psychiatry. 2000;157(4 suppl):1-45.
Considerations in the Decision to
Use Maintenance Treatment
Risk of recurrence
Number of prior episodes; presence
of comorbid conditions; residual
symptoms between episodes
Severity of episodes
Suicidality; psychotic features;
severe functional impairments
Side effects experienced
with continuous treatment
Patient preferences
SPECIFIC CLINICAL FEATURES
INFLUENCING THE TREATMENT PLAN
•
•
•
•
•
Psychiatric Factors
Demographic and Psychosocial Variables
Co-occurring psychiatric disorders
Demographic and Psychosocial Variables
Treatment Implications of Co-occurring
General Medical Conditions
• Co-occurring psychiatric disorders
– Dysthymic disorder
– Affective disorders
– Dementia
– Substance use disorders
– Personality disorders
– Eating disorders
•
•
•
•
•
•
•
•
•
•
•
•
•
Treatment Implications of Co-occurring General Medical Conditions
1. Hypertension
2. Cardiac disease
3. Stroke
4. Parkinson’s disease
5. Epilepsy
6. Obesity
7. Diabetes
8. Sleep apnea
9. Human immunodeficiency virus and hepatitis C infections
10. Pain syndromes
11. Obstructive uropathy
12. Glaucoma
Unmet Needs in Anxiety
• Underdiagnosed therefore untreated
• Faster improvement
• Fewer side effects and better tolerability
• Greater efficacy
• Long term efficacy
Source: Datamonitor, Stakeholder Insight: MDD, Q1.2; Adult population figures from www.census.gov and MDD prevalence rates applied.
National Survey Dispels Notion that Social
Phobia is the Same as Shyness
• social phobia is not simply shyness that has been
inappropriately medicalized
• social phobia affects a minority of youth and only a
fraction of those who consider themselves to be shy
• the greater disability that youth with social phobia
experience and the greater likelihood that they will
have another disorder
• they are not more likely to be getting treatment
compared to their peers, questioning the notion that
these youth are being unnecessarily medicated.
• About half of adults with an anxiety disorder had
symptoms of some type of psychiatric illness by age 15,
a NIMH-funded study shows.
• Results from a small clinical trial suggest that it might
be possible, using computer-based training, to help
children with anxiety shift their attention away from
threat.
• Normal human shyness is not being confused with the
psychiatric anxiety disorder known as social phobia,
according to an NIMH survey comparing the
prevalence rates of the two among U.S. youth.
• Anxiety as a personality trait appears to be
linked to the functioning of two key brain
regions involved in fear and its suppression,
according to an NIMH-funded study.
Differences in how these two regions function
and interact may help explain the wide range
of symptoms seen in people who have anxiety
disorders. The study was published February
10, 2011 in the journal, Neuron.
• Youth with obsessive compulsive disorder
(OCD) who are already taking antidepressant
medication benefit by adding a type of
psychotherapy called cognitive behavior
therapy (CBT), according to an NIMH-funded
study published September 21, 2011, in the
Journal of the American Medical Association.
• Anxiety Linked to Smarts in Brain Study
Tendency to worry may have evolved along
with intelligence in humans, researchers say
Health Tip: When Your Child is
Stressed
• Stress is a fact of life, and children are no less immune than their
parents.
• How can you recognize if your child is "stressed out?" The American
Academy of Pediatrics mentions these possible warning signs:
• Having physical problems, such as stomach ache or headache.
• Appearing agitated, tired or restless.
• Seeming depressed and unwilling to talk about his or her feelings.
• Losing interest in activities and wanting to stay at home.
• Acting irritable or negative.
• Participating less at school, possibly including slipping grades.
• Exhibiting antisocial behavior (stealing or lying), avoiding chores or
becoming increasingly dependent on his or her parents.
• Mental Stress May Be Harder on Women's
Hearts
• Researchers Find Blood Flow to Women's
Hearts Doesn't Increase in Face of Stress
•
•
•
•
•
Psychoeducation: Perhaps one of the most difficult aspects of coping with Social Phobia is simply understanding
what it is, where it came from, why it's so hard to change, and how it keeps coming back with a vengeance.
Psychoeducation involves you and your therapist working together to develop a better way to understand your
Social Phobia, and subsequently, how to work with it.
Cognitive Restructuring: As discussed earlier, individuals with Social Phobia frequently hold negative beliefs about
themselves and others, which often show up as unhelpful thoughts in social situations. Cognitive restructuring is
an important component of CBT, and it involves working with your therapist to identify these thoughts and look
for patterns within them. As you become skilled at noticing these thoughts, you then develop strategies for
gaining flexibility in your thinking and considering more helpful ways of looking at your experiences.
In Vivo Exposure: In vivo (real life) exposure is another core element of CBT for Social Phobia. You and the
therapist identify situations that you avoid because of Social Phobia, and then gradually enter these situations
while accepting your anxiety and allowing it to naturally dissipate. While this step probably sounds quite
intimidating, it is important to know that exposure is done at a very gradual, planned pace, and that your therapist
will support you throughout the process. Many clients report exposure practices as being among the most useful
elements in their treatment.
Interoceptive Exposure: Some individuals with Social Phobia are fearful not only of social situations, but also of
the anxious physical sensations (such as blushing, shaking, sweating, etc.) that can accompany them. Interoceptive
exposure practices deliberately bring about these sensations through such activities as wearing a warm sweater to
induce sweating in social situations. Just as exposure to feared situations leads to reductions in situational fear,
exposure to feared sensations will lead to a reduction in anxiety over experiencing these feelings in social
situations.
Social Skills Training: In the midst of a tense social situation, many people with Social Phobia fear that they do not
have the necessary social skills to successfully navigate the exchange. While this may be due to negative self-talk
and self-consciousness (rather than an actual lack of skill), many people find it helpful to discuss such topics as
carrying on conversations, being assertive, and effective listening. Social skills training provides a chance to work
on these areas in therapy.
Anxiety Disorder Association of
American (ADAA)
• The ADAA brings together professionals
from many disciplines including
psychiatrists, psychologists, social workers,
physicians, nurses, etc. Through networks,
the ADAA increases awareness about
anxiety disorders, provides education
resources, offers access to care, and
supports research.
• www.adaa.org
• http://www.ocfoundation.org/
• Yoga
• Accupuncture
• Warm bath, soothing music, exercise, massage,
stay away from caffeine, Alcohol?, balance diet,
avoid eating to relieve stress, appropiate meal
times
• Alternative and Supplemental Medication
• Books/Autotapes
• Podcast
• Meditation and Mindfullness
• http://www.nimh.nih.gov/
Concluding Thoughts —
• There is a clear and pressing need for faster, robust and
well tolerated therapy/therapies.
• Thinking is rapidly changing and evolving –
combination strategies from treatment initiation may
be the new frontier for patients who need greater
efficacy than antidepressant monotherapy.
• Personalized medicine may be needed to address
genetic differences in depressed individuals to achieve
and maintain remission.
EDUCATIONAL RESOURCES FOR
PATIENTS AND FAMILIES
•
•
•
•
•
•
•
•
http://www.adaa.org/
Healthy Minds, Healthy Lives
National Alliance on Mental Illness
National Institute of Mental Health
National Center for Complementary and
Alternative Medicine
Postpartum Support International
MentalHelp.net
rx
• http://www.ocfoundation.org/CBT.aspx#ERP
• OCD cannot be prevented. However, early
diagnosis and treatment can help reduce the
time a person spends suffering from the
condition
http://www.nami.org/
Epidemiology of PTSD
• Prevalence is 1% in the general population,
and can be as high as 25% in those who have
experienced trauma
• In combat veterans, prevalence is 20%
• Very high prevalence in women who are
victims of sexual trauma
PTSD Costs
• Patients with PTSD are frequent users of the
health care system
• Patients usually present to primary care
physicians with somatic complaints
• After panic disorder, PTSD is the most costly
anxiety disorder
Social Phobia
• Fear of being exposed to public scrutiny
• Fear of behaving in a way which will be
humiliating or embarrassing
• Symptomatic resemblance to panic disorder
with anticipatory anxiety (person may be
anxious/worrying far in advance of the event)
• Extensive phobic avoidance
Social Phobia
• Distinction: anxiety only occurs when the
patient is subject to the scrutiny of others
(public speaking, oral exam, eating in the
cafeteria)
• Phobic stimulus is avoided or endured with
intense anxiety
• Fear and avoidant behaviors interfere with
person’s normal routine or cause marked
distress
Epidemiology: Social Phobia
• Prevalence rates vary depending on study;
overall range is 3 –13% of the population
• Onset in adolescence
• Prevalence greater in females, but greater for
males in clinical samples
• Frequent comorbidity with depression and
substance abuse
Obsessive Compulsive Disorder (OCD)
• Obsessions: recurrent, intrusive, unwanted
thoughts (i.e. fear of contamination)
• Compulsions: behaviors or rituals aimed at
reducing distress or preventing a dreaded
event (i.e. compulsive handwashing)
OCD Symptoms
• Recurrent obsessions and/or compulsions are
severe enough to consume more than one
hour/day
• Person recognizes the obsession as a “product
of his/her own mind”, rather than imposed
from the outside, and that they are
unreasonable or excessive
OCD Symptoms
• The obsessions are “ego-dystonic” (not
enjoyable for the ego), as opposed to “egosyntonic” (the ego likes it)
Common Obsessions
•
•
•
•
•
•
Contamination
Repeated doubts
Order
Aggressive or horrific images
Sexual/pornographic imagery
Scrupulosity
Obsessions and Common Compulsive
Responses
• Contamination: cleaning, hand washing,
showering
• Repeated doubts: checking, requesting or
demanding reassurances from others, counting
• Order: checking, rituals, counting
• Aggressive or horrific images, checking, prayers,
rituals
• Sexual/Pornographic imagery: prayer/rituals
Epidemiology of OCD
• Lifetime prevalence is 2-3% in the general
population
• Mean age of onset is mid-twenties,
although men may develop symptoms
earlier
• Less than 5% of patients develop disease
after age of 35 years
• Chronic course, stress can exacerbate
symptoms
Substance Induced Anxiety Disorder
• Prominent symptoms of anxiety that are
judged to be the direct physiological
consequence of a drug or abuse, a medication
or toxin exposure
Panic Attacks and Panic Disorder
• Panic Attacks
• Agoraphobia without a history of panic
disorder
• Panic Disorder without agoraphobia
• Panic Disorder with agoraphobia
Post Traumatic Stress Disorder
• Characterized by the re-experiencing of an
extremely traumatic event accompanied by
symptoms of increased arousal and by avoidance
of stimuli associated with the trauma
• Symptoms present for at least one month
• If event just occurred and/or symptoms present
for less than one month, a diagnosis of Acute
Stress Disorder is given
Specific Phobia
• Clinically significant anxiety provoked by
exposure to a specific feared object or
situation, often leading to avoidance behavior
Obsessive Compulsive Disorder
• Characterized by obsessions that cause
marked anxiety or distress and/or
compulsions that serve to neutralize anxiety
• Substance Induced Anxiety Disorder
• Anxiety Disorder not otherwise specified

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