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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