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DIFFERENTIATING AND TREATING SYMPTOMS OF ANXIETY IN CASES OF PHYSICAL ILLNESS

DIFFERENTIATING AND TREATING SYMPTOMS OF ANXIETY IN CASES OF PHYSICAL ILLNESS Frank M. Dattilio, Ph.D., ABPP Department of Psychiatry Massachusetts Mental Health Center. RESEARCH FINDINGS

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DIFFERENTIATING AND TREATING SYMPTOMS OF ANXIETY IN CASES OF PHYSICAL ILLNESS

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  1. DIFFERENTIATING AND TREATING SYMPTOMS OF ANXIETY IN CASES OF PHYSICAL ILLNESS Frank M. Dattilio, Ph.D., ABPP Department of Psychiatry Massachusetts Mental Health Center

  2. RESEARCH FINDINGS ▫ Epidemiological studies indicate that approximately 25% of the population will suffer from clinically significant anxiety at some point in their lives. ▫ There is a 12-month prevalence rate of approximately 18%. (Kesseler, et al., 2005) 3

  3. ▫ Anxiety disorders generally maintain a chronic course when untreated and result in substantial impairment across the life span. ▫ Anxiety psychopathology is associated with increased utilization of non-psychiatric medical services. (Pine, Cohen, Gurley, Brook, & Ma, 1998; Ferdinand & Verhulst, 1995; Greenberg, et al., 1999) 4

  4. ▫There is a high co-occurrence of physical illness with anxiety disorders. ▫ Recent statistics indicate that there has been 53 million mental health-related emergency department visits between 1992-2000. 16% of all mental health visits involved anxiety related physical complaints (Smith, et al., 2008). ▫ There are well established associations between panic disorder and cardiorespiratory disorders (i.e., asthma, chronic obstructive pulmonary disease, mitral valve prolapse, etc.). ▫ Many of these medical disorders spawn ongoing symptoms of anxiety that mimic symptoms of the medical illness. (Gorman, Goetz, Fyer, & King, 1988; Karajgi, Rifkin, Doddi, & Kolli, 1990; Smith R. P., Larkin, G. L., & Southwick, S. M., 2008; Weissman, et al., 1990; Zandbergen, et al., 1991).

  5. And of course there are concerns about: ▫ Ethics ▫ Liability ▫ Patients’ welfare 6

  6. ▫ Because of the nature of anxiety symptoms, there is an increased risk for chronic medical conditions, such as: - Hypertension - Migraine headaches - Ulcers - Thyroid Disease - Etc. (Rogers, White, Warshaw, & Yonkers, 1994) 7

  7. Anxiety Psychopathology COMPLEX DYNAMICS Development of Physical Conditions Exacerbate Existing Physical Conditions Development of Anxiety Disorders Non-psychiatric Medical Conditions Exacerbate both Anxiety Symptoms and Medical Symptoms

  8. Sometimes the struggle is in determining whether concurrent non-psychiatric medical conditions are a: ▫ Cause ▫ Consequence ▫ Independent of Anxiety [Mom’s cooking] 9

  9. Models that explain the generation and/or maintenance of anxiety ▫ Cognitive misappraisal of benign bodily sensations that are believed to be a true symptom of a bona fide physical illness. ▫ Interoceptive conditioning that links bodily cues with sympathetic arousal.

  10. Body perturbations are a common and necessary element for the generation of fear of each of these mechanisms. The pressure of physical conditions that create perceivable body perturbations will necessarily place an individual at greater risk for: ▫ Catastrophic misappraisal of sensations ▫ Interoceptively mediated fear response [My GBS] (Dattilio, 2001; Clark, 1986) 11

  11. In both models: ▫ Medical morbidity may contribute to or maintain anxiety problems. ▫ Interplay likely influences response to treatment. ▫ Studies indicate that medically burdened groups continue to exhibit more symptomatology at follow-up due to higher baseline symptoms. (Roy-Byrne, Stein, et al., 2005)

  12. Anxiety related medical illnesses most typically encountered in clinical practice: ▫ Cardiovascular illness/disorder ▫ Neurological illness/disorder ▫ Gastrointestinal disorders (IBS) Some of the lesser encountered are: ▫ Pheocromocytoma ▫ Vistibular disorders

  13. DIFFERENTIATING ANXIETY FROM A HEART ATTACK □ Tricky business due to the overlap of symptoms Cardiovascular disorders with Anxiety-like Symptoms Arrhythmia Tachycardia Coronary Artery Disease Myocardial Infarction (recovery from) Heart Failure Mitral Stenosis Mitral Valve Prolapse Hypertension Postural Orthostatic Hypotension Stroke Transient Ischemic Attack Pulmonary Embolism Pulmonary Edema

  14. CARDIOVASCULAR ILLNESS • Most research to date on the anxiety-Coronary Heart Disease (CHD) link has examined the role of phobic anxiety as a risk factor for CHD (Crown & Crisp, 1966; Kawachi, Colditz, et al., 1994). • A high proportion of patients with established CHD suffer from anxiety disorders (Fleet, et al., 2000; Goldberg, et al., 1990). • Also, patients with non-cardiac chest pain often present to cardiology settings. They are found to have normal coronary angiograms and show no other identifiable medical condition. • These patients also tend to have obsessive/ruminative traits and/or hypochondriacal tendencies. 15

  15. Anxiety is one of several psychosocial stressors that may bring about chronic autonomic imbalance with sympathetic predominance. • Because of the possible mechanism of altered cardiac autonomic tone, it could involve amplified sympathetic stimulation that is associated with the occurrence of arrhythmias or vagal control.

  16. ASSESSMENT Assessment Measures Short-Form Health Survey (SF-36) (Ware & Sherbourne, 1992) Anxiety Disorders Structured Interview-IV (ADIS-IV) (Dinardo, Brown, & Barlow, 1995) BSQ – Body Sensations Questionnaire (Chambless, et al., 1984) CAQ – Cardiac Anxiety Questionnaire (Eifert, et al., 2000) HAQ – Health Anxiety Questionnaire (Lucock & Morley, 1996).

  17. ASSESSMENT QUESTIONS • What are the specific symptoms that contribute to alarm or concern? • Which overlap with the symptoms of the physical illness? • Did symptoms of anxiety preexist the symptoms of the illness? • What are your specific schemas about these symptoms and their relationship to the physical illness? • Specific trauma caused by the illness (i.e., fear of death, incapacitation, etc.). • Concerns about loss of control (i.e., I can’t trust my body, I’m deteriorating, etc.). • Fear of death. • Denial.

  18. ASSESSMENT - Label the catastrophic interpretation of the symptoms for both the illness and the anxiety Heart attack? Determining Factors? e.g., Increased heart rate Benign over-activity? Determining Factors? - What is your belief about your tendency to overrate or misinterpret severity of symptoms?

  19. ASSESSMENT • What is the patient’s medical knowledge about their illness and symptoms? • Knowledge level about procedures conducted and likelihood of reoccurrence of cardiac episode? • Review of medical report and consultation with cardiologist/internist, etc. • The patient’s own awareness of their tendency to misinterpret body sensations.

  20. TREATMENT INTERVENTIONS PHARMACOTHERAPY VS. PSYCHOTHERAPY OR BOTH?

  21. ANTIDEPRESSANTS ▫ Monoamine oxidase inhibitors (MAOI’s) ▫ Tricyclic antidepressants (TCA) ▫ Serotonin Selective Uptake Inhibitors (SSRI) All have demonstrated the highest levels of efficacy in the treatment of anxiety disorders. (Sammons & Schmidt, 2001)

  22. Antidepressants – Rx of choice Superior to Benzodiazepines for several reasons: ▫ Less withdrawal and dependency effects ▫ Do not mask underlying depression ▫ SSRI’s traditionally have lower side effect profiles (i.e., fewer to none peripheral-vascular effects) Despite the above, Benzodiazepines have more appeal due to rapid anxiolytic effects. - Drawbacks: may mask underlying depression and is habit forming. - Also, patients have a tendency to rely more on the medication than their own resources.

  23. COGNITIVE-BEHAVIOR THERAPY ▫ Psychoeducation ▫ Cognitive reappraisal of symptoms ▫ Anxiety management procedures (PMR, breathing control skills; mindfulness meditation, etc.). Reducing the level of anxiety. Reducing the patient’s distortion in interpretation. ▫ Exposure-based interventions - Interoceptive exposure - Repeated exposure to bodily sensations associated with the threat of feared response - Imaginal exposure - Homework - Therapeutic Alliance (Collaborative Empiricism)

  24. PSYCHOEDUCATION – “Crescat Scientia” ▫ Didactic education about the physiological principles of anxiety, as well as about the specific medical illness. - dispelling mystery as well as myth (uncertainty increases anxiety) - expanding one’s knowledge about the specific symptomatology of their physical illness - how we differentiate the benign from the seriously threatening – judgment calls - Reviewing the medical procedures conducted - Likelihood of reoccurrence - Accepting what we can and cannot control - Tolerance Building

  25. □ Heart Attack or Myocardial Infarction (MI) results when the coronary artery becomes occluded (i.e., small blood clot can become lodged in a fat-clogged artery and completely cut off blood and O2 to a portion of the heart). Symptoms: Uncomfortable pressure, squeezing or pain in the center of the chest that is usually much deeper than the intercostal chest wall tension experienced during anxiety.

  26. - Pain associated with an MI is generally beneath the breastbone and may last more than just a few minutes. - Pain may spread to shoulder, arms, elbow, jaw, or even the high abdominal area. - Pain may grow increasingly severe and be associated with dizziness, fainting, sweating, shortness of breath, nausea, vomiting, or severe anxiety. 27

  27. SYMPTOM-AUTOMATIC THOUGHT-EMOTION/BEHAVIOR: ANXIETY SEQUENCE REGARDING PERCEIVED HEART ATTACK SymptomAutomatic ThoughtEmotion/Behavior Increased Is this the start of a Worry heart rate heart attack? Difficulty Oh, no! I can’t breathe! Vigilance, gasping breathing for more air Hot flashes and This is getting worse. Fidgety and unable and sweating to relax Tingling in hands This is terrible, it’s Nervousness and and feet happening again worry Lightheadedness I need to get medical Fear attention. I don’t want to die.

  28. RESTRUCTURING OF INTERPRETATIONS OF SYMPTOMS SymptomAutomatic ThoughtEmotion/Behavior Increased heart This may just be a natural Deep breath and rate variation in my heart rate relax Difficulty breathing Don’t get worked up Controlled breathing Hot flashes and Natural reaction to increase Bring your heart rate sweating in breathing and heart rate back down Tingling in hands This happens with over- Bring your heart rate and feet breathing, just relax and back down focus Lightheadedness This happens with over- Reduce your heart breathing, just relax and rate focus

  29. ESTABLISHING SAFETY NETS • Establishing hot line with cardiologist/internist’s office for interim period vs. emergency department visits. • Audio/video tape recording of patient or therapist walking through the steps of assessing severity. • Self-talk procedures. • Group support programs.

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