Download Don`t Panic: How to Manage Anxiety Disorders

Don’t Panic: How to Manage
Anxiety Disorders
Kimberly Stoner, MD, MS, FACP
Assistant Professor Division of General
Internal Medicine and Department of
Psychiatry & Behavioral Medicine
www.mcw.edu
Learning Objectives
• Highlight key features of DSM IV anxiety
disorders with an emphasis on panic
disorder
• Review the anxiolytics in the evidencebased guidelines for the pharmacological
treatment of anxiety disorders per the
British Association for
Psychopharmacology
• Describe a practical approach for referring
patients for psychotherapy
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Why Anxiety Disorders Matter
• Prevalence is 19.5% in primary care
Kroenke K, Spitzer RL, Williams JB, Monahan PO, Lowe B. Anxiety
disorders in primary care: prevalence, impairment, comorbidity &
detection. Ann Intern Med 2007;146:317-25
• Untreated in 41%
• Up to 35.6% of patients with untreated
anxiety self-medicate with drugs/alcohol
Bolton J, Cox B, Clara I, Sareen J. Use of alcohol and drugs to selfmedicate anxiety disorders in a nationally representative sample. J
Nerv Ment Dis 2006;194:818-25
• Treatment was easy in the CALM trial
medications + Cognitive Behavioral Therapy
Roy-Byrne P, Craske MG, Sullivan G, Rose RD, Edlund MJ, et al. Delivery
of evidence-based treatment for multiple anxiety disorders in primary
care: a randomized controlled trial. JAMA. 2010;303:1921-28
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Anxiety Disorders
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Substance Induced Anxiety Disorder
Anxiety due to medical condition
Panic Disorder +/- agoraphobia
Generalized Anxiety Disorder
Social phobia/social anxiety disorder
Obsessive-Compulsive Disorder
Posttraumatic Stress Disorder
Acute Stress Disorder
Specific phobia
Anxiety NOS
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Diagnostic Pearls
• Acute stress disorder is <4weeks, at
one month mark = post traumatic
stress disorder
• Don’t confuse obsessive compulsive
disorder with obsessive compulsive
personality disorder
• Generalized Anxiety Disorder need to
be a worrier for at least 6 months
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Treatment Strategies Specific
to type of anxiety disorder
• Substance induced anxiety- stop it
• Anxiety due to medical conditiontreat it
• Specific phobia- exposure
• Panic disorder patients with frequent
attacks deserve a benzodiazepine
bridge to prevent agoraphobia
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Panic Disorder
• Recurrent, unexpected panic attacks
• Worry about having another attack,
the implication of the attack, or
change in behavior due to attack
• Not due to substance or medical
condition
• With or without agoraphobia
• Panic attack: a discrete period of
intense fear with 4 or more
symptoms with abrupt onset that
peaks in 10 minutes
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Panic Attack Symptoms
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Palpitations, heart racing/pounding
Sweating
Trembling/shaking
Shortness of breath/smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Dizzy, lightheaded, faint
Derealization or depersonalization
Fear of losing control or going crazy
Fear of dying
Paresthesias
Chills or hot flushes
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Is it Panic Disorder?
• Most panic disorder patients have
had at least one unprovoked attack
• Panic attacks don’t last for hours
• Most patients will have positive
family history of panic or alcoholism
• Most patients will be able to describe
4+ symptoms without you giving
them the list
• “Tell me about the first time you
ever had a panic attack.”
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Treating Panic Disorder per
American Psychiatric Association
Guidelines
• Assess for suicidality and depression
• Use a controller medication SSRI or
SNRI>TCA>>MAOI
• Mirtazapine & anticonvulsants if
conventional treatments fail
• Frequent visits to titrate medication
• Use a benzodiazepine if rapid symptom
control needed
• Assume more sensitive to medication side
effects- start low
• Cognitive Behavioral Therapy
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First Line Anxiety Rx- SSRIs
• Sertraline (OCD, Panic, PTSD, Social
Anxiety)
• Escitalopram (GAD)
• Fluoxetine (OCD, Panic Disorder)
• Fluvoxamine (OCD, Social Anxiety)
• Paroxetine (Social Anxiety, Panic,
GAD, PTSD)
• Citalopram
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How to Pick Which SSRI
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What worked for a family member
Cost/insurance formulary
If constipated – sertraline
If noncompliant and need to lose
weight -fluoxetine
• If need easy titration -escitalopram
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First Line Anxiety Rx- SNRIs
• Venlafaxine (GAD, social anxiety,
Panic) not good for GERD patients or
patients with hypertension
• Desvenlafaxine
• Duloxetine
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Benzodiazepines
• GOOD safe and effective for most
patients, provide quick relief of target
symptoms like anxiety
• BAD sedation, incoordination
• UGLY potentially lethal in overdose, risk
of abuse, drug diversion, withdrawal
syndromes
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Benzodiazepine Use
1. Diagnose a condition for which a
benzodiazepine is indicated
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Panic disorder
Obsessive Compulsive Disorder
Generalized Anxiety Disorder
Post traumatic stress disorder
Social Anxiety Disorder
Primary insomnia
Seizures
Muscle spasms
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Benzodiazepine Use
2. Document failure of first line
therapy either due to residual
symptoms or intolerable side effects
• Selective Serotonin Reuptake Inhibitor
(SSRI) or SNRI venlafaxine (Effexor)
• Functional impairment due to anxiety that
warrants temporary benzodiazepine use
while SSRI is titrated
• Psychotherapy
• Sleep hygiene
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Benzodiazepine Use
3. Conduct and document a riskbenefit discussion with patient
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Consider history of addiction
Document patient’s alcohol use
Warn patient about risk of driving
Identify target symptoms
List specific potential benefits that can be
evaluated for and recorded
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Benzodiazepine Use
4. Select the appropriate
benzodiazepine
• FDA approved indication Anxiety:
Chlordiazepoxide, diazepam & lorazepam
Panic Disorder: clonazepam
• Short vs. long half life
• Active metabolites
• Drug interactions
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Benzodiazepine Use
5. Dispense the appropriate number of
pills
• Intended for chronic or temporary use
• Do not write for multiple months supply if
follow up is in weeks
• If it is appropriate to dispense a
significant quantity, document an
assessment of suicidality
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Benzodiazepine Use
6 Follow Up
• Document side effects
• Document benefits
• Monitor for signs of misuse lost
prescriptions, early refills, rapid dose
escalation, urine drug screen, pill count
• Enact a discontinuation plan when
appropriate to ensure safe taper
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Second Line Anxiety Rx Options
• Mirtazapine : no sexual dysfunction,
helps nausea, helps with sleep,
stimulates appetite,
• TCAs
Mostly norepinephrine: desipramine,
nortriptyline
Mostly serotonin: Clomipramine(OCD)
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Second Line Augmentation
• Anticonvulsants: gabapentin,
pregabalin quicker onset
• Serotonin Agonist: buspirone
• Beta blockers: pindolol, propranolol
good for panic
• Antihistamine: hydroxyzine for
patients who need a prn but you are
reluctant to give benzodiazepine
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Third Line Anxiety Rx Options
• MAOIs
• Augmentation with a low dose
atypical antipsychotics olanzapine,
quetiapine, risperidone (all have risk
of metabolic syndrome)
• Augmentation with a low dose of
haloperidol
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American Diabetic Association
American Psychiatric Assn
Consensus Guidelines
• Family History of diabetes
• Weight (week 4, 8, 12 then quarterly:
intervene if 5% up from baseline)
• BMI (>28.7 =metabolic syndrome)
• Waist Circumference
• Blood pressure (3 months after start)
• Fasting lipid levels (3 months after start)
• Fasting glucose levels (3 months after
initiation of medication)
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Alternative Medicine
• chamomile at least has some data
(one small RCT in GAD),
• Kava poor evidence
• Valerian poor evidence
• St John’s Wort poor evidence
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Not an Anxiety Medication
• Bupropion a dopaminergic drug
(depression, seasonal affective
disorder, smoking cessation)
• Does not work for anxiety
• Unless the patient has become a
worrier due to depression
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Psychotherapy
• The side effect free treatment for
anxiety disorders
• Cognitive behavioral therapy has the
most evidence in terms of RCTs
showing efficacy
• Most patients also benefit from
relaxation techniques
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How do I find a therapist?
http://www.psychologytoday.com
• Find a therapist by zip code
• Red Check Mark “verified by
psychology today” Wisconsin license
valid without disciplinary action
• Areas of expertise
• Treatment orientation: CBT
• Payment options
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Summary of Key Points
• Most patients with anxiety disorders will need a
controller medication (SSRI/SNRI and not just a
rescue)
• For patients needing rapid symptom control use a
benzodiazepine bridge
• Most common mistake in treating anxiety disorder
in primary care setting is not seeing patient back
frequently enough in order to titrate the dose of the
drug to an adequate level
• Psychotherapy is the only treatment without
negative side effects
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