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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 www.mcw.edu 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 www.mcw.edu Anxiety Disorders • • • • • • • • • • 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 www.mcw.edu 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 www.mcw.edu 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 www.mcw.edu 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 www.mcw.edu Panic Attack Symptoms • • • • • • • • • • • • • 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 www.mcw.edu 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.” www.mcw.edu 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 www.mcw.edu 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 www.mcw.edu How to Pick Which SSRI • • • • 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 www.mcw.edu First Line Anxiety Rx- SNRIs • Venlafaxine (GAD, social anxiety, Panic) not good for GERD patients or patients with hypertension • Desvenlafaxine • Duloxetine www.mcw.edu 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 www.mcw.edu Benzodiazepine Use 1. Diagnose a condition for which a benzodiazepine is indicated • • • • • • • • Panic disorder Obsessive Compulsive Disorder Generalized Anxiety Disorder Post traumatic stress disorder Social Anxiety Disorder Primary insomnia Seizures Muscle spasms www.mcw.edu 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 www.mcw.edu Benzodiazepine Use 3. Conduct and document a riskbenefit discussion with patient • • • • • 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 www.mcw.edu 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 www.mcw.edu 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 www.mcw.edu 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 www.mcw.edu 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) www.mcw.edu 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 www.mcw.edu 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 www.mcw.edu 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) www.mcw.edu 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 www.mcw.edu 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 www.mcw.edu 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 www.mcw.edu 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 www.mcw.edu 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 www.mcw.edu