Anxiety and its Presentation in Primary Care

1. Anxiety and its Presentation in Primary Care Kara Z. McDaniel, NCC, LPC Emory Family Medicine/Behavioral Medicine

2. Pathophysiology and Clinical Presentation • What is anxiety? • What is pathologic anxiety? • Manifestation of anxiety

3. Most common of all mental disorders. May occur independently or in conjunction with other disorders, most specifically Mood Disorders and Substance-Related Disorders. More than one type of anxiety disorder may occur at the same time. Anxiety Disorders

4. Prevalence • Anxiety disorders are more common in women than in men with men presenting 40-45% of the time. • It is estimated that 5% of the population will experience an anxiety disorder at some time during the life span.

5. Prevalence • There is a family association with anxiety disorder. Although environment is certainly a factor, twin studies indicate a genetic contribution as well. • The expression of anxiety is influenced by culture. It is critical that the cultural background of the person presenting be considered when completing evaluations.

6. Adjustment Disorder with Anxious Mood • Adjustment Disorder with Anxious Mood • Age • Gender • Culture

7. Adjustment Disorder with Anxious Mood • Diagnostic Criteria • Symptoms, emotionally and behaviorally, experienced 3 months of the onset of stressor • Suffer from symptoms similar to GAD • Symptoms/behaviors are clinically significant • Distress that is in excess of what would be expected • Impaired functioning, socially, academically, etc.

8. Adjustment Disorder with Anxious Mood • Diagnostic Criteria, continued • Does not meet criteria for any other mental disorder • Symptoms are not consistent with Bereavement • Symptoms do not persist for 6 months after termination of stressor • Excessive anxiety emerges until patient is able to adjust • Typically resolves in less than 6 months

9. Generalized Anxiety Disorder • GAD • Gender • Etiology • Comorbidity

10. Generalized Anxiety Disorder • Diagnostic Criteria • Excessive worry about many different events • Occurring more days than not over 6 months • Worry is difficult to control • Not due to any other medical condition, substance abuse, or mental disorder

11. Generalized Anxiety Disorder • Diagnostic Criteria, continued • Interferes with normal functioning and causes significant distress in areas of one’s life • Must have three of the following symptoms: • Restlessness • feeling on edge • Easily fatigue • Difficulty concentrating • Irritability • Muscle tension • Sleep disturbance

12. Obsessive Compulsive Disorder • OCD • Onset • Clinical Course • Comorbidity • Familial Pattern • Symptoms of OCD • Obsessions • Compulsions

13. Obsessive Compulsive Disorder • Diagnostic Criteria • Either Obsessions or Compulsions • Obsessions • Recurrent impulses, ideas, or images that are unwanted and intrusive • Excessive worrying is not focused on real-life problems • Person attempts to ignore and neutralize • Thoughts are product of one’s mind

14. Obsessive Compulsive Disorder • Diagnostic Criteria, continued • Compulsions • Repetitive behaviors • Performed in a ritualized manner to alleviate/neutralize anxiety • At some point in time, individual has recognized that obsessions/compulsions are excessive • Causes marked distress, time consuming (e.g. more than one hour per day), or significantly interferes with functioning

15. Obsessive Compulsive Disorder • Diagnostic Criteria, continued • Content of obsessions/compulsions is not restricted to another Axis I disorder if present • Eating D/O • preoccupied with food • Not due to effects of a substance or general medical condition • Specify if: • With Poor Insight

16. Panic Disorder • Panic Disorder • Gender • Onset • Comorbidity • Cultural and familial effects

17. Panic Disorder • Diagnostic Criteria • Panic Disorder without Agoraphobia • Characterized by panic attacks that are recurrent and unexpected • followed by at least one month of persistent concern of experiencing another panic attack • worry about the consequences and implications of the attack • change in behavior that is significant and related to attacks • concern about having additional attacks

18. Panic Disorder • Diagnostic Criteria, continued • Panic Disorder without Agoraphobia • Absence of Agoraphobia • Events are avoided or endured with marked distress/anxiety • Anxiety/avoidance cannot be better accounted for another mental disorder or medical condition

19. Panic Disorder • Diagnostic Criteria, continued • Panic Disorder without Agoraphobia • Panic attacks are not due to effects of substance or general medical condition • Panic attacks are not due to another mental disorder

20. Panic Disorder • Diagnostic Criteria, continued • Panic Disorder with Agoraphobia • Recurrent/unexpected panic attacks • followed by at least one month of persistent concern of experiencing another panic attack • worry about the consequences and implications of the attack • change in behavior that is significant and related to attacks • concern about having additional attacks

21. Panic Disorder • Diagnostic Criteria, continued • Panic Disorder with Agoraphobia • Presence of Agoraphobia • Avoidance of places in which getting help or escaping may be difficult in the event of a panic attack • Panic attacks are not due to effects of substance or general medical condition • Panic attacks are not due to another mental disorder

22. Acute Stress Disorder • Diagnostic Criteria • Exposure to a traumatic event in which both of the following were present • Experienced, witnessed, or confronted with an event that involved actual/threatened death or serious injury, or a threat to one’s physical integrity or to someone else • Response involved fear, helplessness, or horror I

23. Acute Stress Disorder • Diagnostic Criteria, continued • Individual has three or more of the following either while or after experiencing the traumatic event • Numbing, detachment, or absence of emotions • Decline in one’s awareness of surroundings • daze • Derealization • Depersonalization • Dissociative amnesia • inability to recall aspects of event

24. Acute Stress Disorder • Diagnostic Criteria, continued • Event is reexperienced in one of following ways • Images • Thoughts • Dreams • Flashbacks • Sense of reliving experience • Illusions • Distress when exposed to reminders of event

25. Acute Stress Disorder • Diagnostic Criteria, continued • Avoidance of stimuli that bring back recollections of trauma • Marked symptoms of anxiety/increased arousal • Distress lasts for minimum of 2 days, maximum of 4 weeks and occurs within 4 weeks of event • Not due to effects of substance or general medical condition • Not due to another mental disorder

26. Post-traumatic Stress Disorder • PTSD • develops after exposure to a traumatic event • also termed shell shock or battle fatigue • reported in persons who have experienced • rape • fire • abuse • war • motor vehicle accidents

27. Post-traumatic Stress Disorder • Diagnostic Criteria • Exposure to a traumatic event in which both of the following were present • Experienced, witnessed, or confronted with an event that involved actual/threatened death or serious injury, or a threat to one’s physical integrity or to someone else • Response involved fear, helplessness, or horror

28. Post-traumatic Stress Disorder • Diagnostic Criteria, continued • Reexperiencing traumatic event • Recollections of the event through the following • Images • Thoughts • perceptions • Dreams • Reexperiencing the event as though it was occurring • flashbacks

29. Post-traumatic Stress Disorder • Diagnostic Criteria, continued • Psychological distress caused by exposure to cues, internally/externally • Physiological distress caused by exposure to cues, internally/externally

30. Post-traumatic Stress Disorder • Diagnostic Criteria, continued • Avoidance of situations associated with the trauma by three or more of the following • Avoid thoughts, feelings, or conversations associated with trauma • Avoid activities, places, or people that remind person of trauma

31. Post-traumatic Stress Disorder • Diagnostic Criteria, continued • Inability to recall aspects of trauma • Marked decline in interest or participation in activities • Feeling detached or estranged from others • Range of affect is restricted • Does not see long future ahead

32. Post-traumatic Stress Disorder • Diagnostic Criteria, continued • Increased arousal indicated by two or more of following • Difficulty falling or staying asleep • Irritability or angry outbursts • Concentration difficulties • Hypervigilance • Startled response is exaggerated

33. Post-traumatic Stress Disorder • Diagnostic criteria, continued • Symptoms lasting over 1 month • Causes significant distress/impairment in one’s life

34. Post-traumatic Stress Disorder • Diagnostic Criteria, continued • May have delayed onset 6 months after traumatic experience • Categorized by when symptoms occur and how long symptoms persist • Acute • Symptoms last between one and three months after event • Chronic • Symptoms last more than three months after event • Delayed Onset • Symptoms do not appear until at least six months after event

35. Specific Phobias • Formerly termed Simple Phobias • Specific Phobias • Age • Familial pattern • Environmental • Sex ratio • Comorbidity

36. Specific Phobias • Diagnostic Criteria • irrational fear in relation to a specific stimulus • fear is excessive and unreasonable • exposure to stimulus elicits an anxious response which may lead to panic attacks • person recognizes that fear is excessive or unreasonable

37. Specific Phobias • Diagnostic Criteria, continued • stimulus is either avoided or endured with much distress and anxiety • avoidance of the stimulus may interfere with other aspects of patient’s functioning • Duration is at least six months for persons under the age of 18 • Not better explained by another mental disorder

38. Specific Phobias • Diagnostic Criteria, continued • Sub-types of Specific Phobias • Animal type • Arachnophobia-Fear of spiders • Natural environment type • Acrophobia-fear of heights • storms • water

39. Specific Phobias • Diagnostic Criteria, continued • Blood-injection-injury type • Situational type • Claustrophobia- Fear of enclosed/confined spaces • Other • fear of choking • Vomiting • contracting illness • Symptoms

40. Social Phobia(Social Anxiety Disorder) • Social Phobia • Onset • Sex ratio • Familial pattern • Comorbidity • Distinguish social phobia from performance anxiety

41. Social Phobia(Social Anxiety Disorder) • Diagnostic criteria • Intense fear of social situations which causes anxiety • Exposure to social situation provokes anxiety • recognizes that fear is excessive or unreasonable • avoid interactions with others or endure distress and anxiety

42. Social Phobia(Social Anxiety Disorder) • Diagnostic Criteria, continued • interferes with one’s functioning and causes significant distress • Duration is at least 6 months for persons under the age of 18 • cannot be better accounted for by substance abuse, medical condition, or mental disorder • Specify if: • Generalized • Fears include most social situations

43. Substance Induced Anxiety Disorder • Diagnostic Criteria • Anxiety, panic attack, or obsessions/compulsions predominate in clinical picture • Evidence from history, physical exam, or lab results of either • Symptoms in first criteria developed during or within 1 month of substance intoxication or withdrawal

44. Substance Induced Anxiety Disorder • Diagnostic Criteria, continued • Not better accounted for by an anxiety disorder that is not induced by substances • Disturbance does not occur only during course of delirium • Causes significant distress/impairment in one’s life

45. Substance Induced Anxiety Disorder • Specify if: • With generalized anxiety • With panic attacks • With obsessive-compulsive symptoms • With phobic symptoms • Specify if: • With onset during intoxication • With onset during withdrawal

46. Anxiety Due to a General Medical Condition • Anxiety Due to a General Medical Condition • Medical conditions that may cause anxiety symptoms • Endocrine • Cardiovascular • Respiratory • Metabolic • Neurological

47. Anxiety Due to a General Medical Condition • Diagnostic Criteria • Anxiety, panic attack, or obsessions/compulsions predominate in clinical picture • Evidence from history, physical exam, or lab results indicate that symptom(s) are caused by general medical condition • Not accounted for by another mental disorder

48. Anxiety Due to a General Medical Condition • Diagnostic Criteria, continued • Disturbance does not occur during course of delirium • Causes distress and impairment in areas of one’s life • Specify if: • With generalized anxiety • With panic attacks • With obsessive-compulsive symptoms

49. Anxiety Disorder NOS • Includes those disorders with anxious/phobic avoidance characteristics that do not meet the criteria for any of the disorders previously discussed

50. Treatment via Therapy • Psychotherapy • Types of treatment • Insight-oriented therapy • Behavioral Therapy • Relaxation Techniques • Cognitive-behavioral therapy