Download 10:30 AM Anxiety - Vanderbilt University Medical Center

Anxiety: Clinical Management
Richard C. Shelton, M.D.
Departments of Psychiatry and Pharmacology
Vanderbilt University School of Medicine
Goals
• Be aware of the diagnostic features of generalized
anxiety, obsessive-compulsive disorder, and panic
disorder.
• Learn about the common clinical presentation of
these disorders in the general medical setting.
• Become familiar with the ways in which these
problems are treated.
Background: Epidemiology
ECA Study, 1984
Primary Anxiety Disorders: 17.2%
Primary Mood Disorders:
11.3%
DSM IV Anxiety Disorders
• Generalized anxiety disorder
• Panic disorder/Agoraphobia
• Obsessive-compulsive disorder
• Acute stress disorder
• Post-traumatic stress disorder
• Specific phobia
• Social phobia
• Adjustment disorder with anxious mood
• Anxiety due to substance/medical condition
• Anxiety disorder NOS
The Structure of Mood
Somatic Anxiety
Tachycardia, diaphoresis,
tachypnea, tremor, etc.
General Distress
Depression/sadness
Hopelessness
Pessimism
Dissatisfaction
Failure/self-blame
Tearfulness
Fatigue/tiredness
Poor concentration
Worry/rumination
Tension
Nervous/restless
Feeling “keyed-up”/“edgy”
Positive Affect
+
Happy/cheerful
Energetic
Proud/optimistic
Sociable
Good concentration
Confident
Interested
+
+
_
_
_
Watson et al. J Abnorm
Psychology 104:15-25,
1995
Differential Diagnosis
Positive affect
Major depression
Somatic anxiety
Panic/phobic Disorders
OCD*
General distress
Generalized anxiety
disorder
Anxiety Disorders: Unique Features
• Obsessive-compulsive disorder:
- Obsessions (“nonsense”)
- Compulsive behavior (rituals)
• Post-traumatic stress disorder: Dissociation
• Phobic disorders (somatic anxiety)
- Fears
- Aversions
• Panic disorder: Episodic hyperarousal (somatic anxiety)
• Generalized anxiety disorder: Persistent distress
Anxiety Disorders: Diagnostic Problems
• Diagnostic overlap: Affective disorders
• Co-morbidity:
- Increased illness severity
- Greater impairment
- More chronically ill
- Poorer response to treatment
- More likely to commit suicide
• Lack of recognition/screening
Anxiety: Pharmacotherapy Management
Anxiety Symptoms
Chronic anxiety
(GAD)
Acute anxiety
(Adjustment d/o)
Panic disorder
OCD
Buspirone
SSRI’s
Venlafaxine
Benzodiazepines
SSRI’s
Benzodiazepines
SSRI’s
Generalized Anxiety Disorder
DSM IV Diagnostic Criteria
• Excessive anxiety for at least six months about a
number of events or activities
• The person finds it difficult to control the worry
• Three or more of the following:
-
Restlessness
Easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbance
Remember
Temperament
Generalized Anxiety Disorder: Treatment
• Cognitive behavioral therapy
- Depression? > +medication
• Medications
-
Buspirone (Azapirone)
SSRI’s
Venlafaxine (SNRI)
Benzodiazepines (avoid if possible)
• Medications not recommended
- Beta blockers (depression)
- Antipsychotics (typical or atypical)
- Gabapentin/pregablin (side effects)
Panic Disorder
DSM IV Diagnostic Criteria
Recurrent unexpected Panic Attacks (discreet - 10-60 min):
• Palpitations/tachycardia
• Sweating
• Trembling or shaking
• Shortness of breath or smothering
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady,
lightheaded, or faint
• Derealization or depersonalization
• Paresthesias (numbness or
tingling)
• Chills or hot flashes
• Fear of losing control or going
crazy
• Fear of dying
Panic Disorder
DSM IV Diagnostic Criteria (cont.)
> 1 month of one of the following:
•
•
•
Persistent concern about having additional attacks
Worry about the implications of the attack/consequences
A significant change in behavior (e.g., agoraphobic
avoidance)
Panic Disorder:
Parsimonious Concepts
•
•
More than one panic attack PLUS
A change in:
- Thinking (worry/fear) OR
- A change in behavior (avoidance)
Panic Disorder with Agoraphobia:
Evolution
Limited symptom attacks
Panic attack
“Help-seeking”
Limited phobias
“Social phobias”
Extensive phobic avoidance
Depression
Panic Disorder/Agoraphobia
Treatment
Psychotherapy
• Behavioral therapy
• Cognitive-behavioral psychotherapy*
Panic Disorder/Agoraphobia
Treatment (cont.)
Medications:
• Tricyclic antidepressants
• Serotonin-selective
antidepressants
- Imipramine [Tofranil]
- Paroxetine [Paxil]
- Amitriptyline [Elavil]
- Clomipramine [Anafranil] - Sertraline [Zoloft]
• MAOI
- Phenelzine [Nardil]
• Benzodiazepines
- Alprazolam [Xanax]
- Clonazepam [Klonopin]
Benzodiazepines:
Should We Use Them?
Advantages
Disadvantages
• Effective
• Rapid onset of action
• Safety
• CNS side effects
• Active metabolites
(elderly/medically ill)
• Potential for abuse
• Potential for physical/
psychological dependence
Facts about benzodiazepine abuse
• Rates of true abuse/addiction are low
• If abused, benzodiazepines are usually “secondary”
drugs of abuse in a polydrug abuse pattern
- “Self-medication”
• Tolerance to the antianxiety effects is low
• Rates of dependency are high with chronic use
Principles for benzodiazepine use
• Clear indication/diagnosis
• Consider “non-drug” or “alternative drug” therapies first
• Remember:
- The benzodiazepine doesn’t correct “the problem”
- Most benzodiazepine-seeking results from trying to
suppress chronic symptoms
• Use brief, interrupted courses of therapy if possible
• Monitor & regularly evaluate efficacy/continued need
• Discontinue gradually if regular use > one month
Understand: If you start it, the patient runs the risk of
long-term need for it
Physical dependence is the result of the physician’s
choice
Obsessive-Compulsive Disorder
Obsessions
Compulsions
• Contamination
• Doubt
• Somatic
• Symmetry
• Impulses
• Washing
• Checking
• Counting
• Confessing
• Symmetry
• Hoarding
(aggression/sex)
OCD: Diagnostic Considerations
• Major depression
- Psychotic MDD
• Other anxiety disorders
• Psychotic disorders
- Schizophrenia
- Delusional disorder
• Somatoform disorders
- Somatization disorder
- Hypochondriasis (etc.)
• Body dysmorphic disorder
• Obsessive-compulsive
personality disorder
- Pre-occupation with details,
lists, rules, order
- Perfectionism
- Overly conscientious,
scrupulous, inflexible, rigid,
stubborn, (miserly)
- Unable to discard things
•
Paraphilias
• Eating disorders
•
Autism/Asperger’s disorder
• Impulse disorders (gambling)
• Substance abuse/dependence
Obsessive-Compulsive Disorder
Recognition in Clinical Practice
• Telltale signs
-
Dermatitis
Repetitive movements
Hoarding
Incompleted tasks
• Screening questions
- “Do you have thoughts that distress you that you
can’t get rid of?”
- Do you have to wash your hands over and over?”
- Do you have to check things repeatedly?”
Obsessive-Compulsive Disorder
Treatment
• Behavioral therapy
- Exposure with response prevention
• Medications
-
Clomipramine (Anafranil) 100-250 mg./day
Paroxetine (Paxil) 20-50 mg./day
Fluvoxamine (Luvox) 100-300 mg./day
Sertraline (Zoloft) 50-200 mg./day