Anxiety: Clinical Management

1. Anxiety: Clinical Management Richard C. Shelton, M.D. Departments of Psychiatry and PharmacologyVanderbilt University School of Medicine

2. 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.

3. Background: EpidemiologyECA Study, 1984 Primary Anxiety Disorders: 17.2% Primary Mood Disorders: 11.3%

4. 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

5. + + + _ _ _ 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

6. Differential Diagnosis Positive affect Major depression Panic/phobic Disorders OCD* Somatic anxiety Generalized anxiety disorder General distress

7. 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

8. 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

9. Acute anxiety (Adjustment d/o) Panic disorder OCD Chronic anxiety (GAD) Buspirone SSRI’s Venlafaxine Benzodiazepines SSRI’s Benzodiazepines SSRI’s Anxiety: Pharmacotherapy Management Anxiety Symptoms

10. Generalized Anxiety DisorderDSM 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

11. 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)

12. 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 DisorderDSM IV Diagnostic Criteria • Recurrent unexpected Panic Attacks (discreet - 10-60 min):

13. Panic DisorderDSM 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)

14. Panic Disorder:Parsimonious Concepts • More than one panic attack PLUS • A change in: • Thinking (worry/fear) OR • A change in behavior (avoidance)

15. Panic Disorder with Agoraphobia:Evolution • Limited symptom attacks • Panic attack • “Help-seeking” • Limited phobias • “Social phobias” • Extensive phobic avoidance • Depression

16. Panic Disorder/AgoraphobiaTreatment Psychotherapy • Behavioral therapy • Cognitive-behavioral psychotherapy*

17. Medications: Tricyclic antidepressants Imipramine [Tofranil] Amitriptyline [Elavil] Clomipramine [Anafranil] MAOI Phenelzine [Nardil] Serotonin-selective antidepressants Paroxetine [Paxil] Sertraline [Zoloft] Benzodiazepines Alprazolam [Xanax] Clonazepam [Klonopin] Panic Disorder/AgoraphobiaTreatment (cont.)

18. Benzodiazepines:Should We Use Them? Advantages • Effective • Rapid onset of action • Safety Disadvantages • CNS side effects • Active metabolites (elderly/medically ill) • Potential for abuse • Potential for physical/ psychological dependence

19. 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

20. 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

21. Obsessions Contamination Doubt Somatic Symmetry Impulses (aggression/sex) Compulsions Washing Checking Counting Confessing Symmetry Hoarding Obsessive-Compulsive Disorder

22. Major depression Psychotic MDD Other anxiety disorders Psychotic disorders Schizophrenia Delusional disorder Somatoform disorders Somatization disorder Hypochondriasis (etc.) Eating disorders Impulse disorders (gambling) 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 Autism/Asperger’s disorder Substance abuse/dependence OCD: Diagnostic Considerations

23. Obsessive-Compulsive DisorderRecognition 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?”

24. Obsessive-Compulsive DisorderTreatment • 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