Transcript Title (right justify / Arial)

PIPC® Psychiatry In Primary Care
ANXIETY DISORDERS
Robert K. Schneider, MD
Departments of Psychiatry, Internal Medicine
and Family Practice
The Medical College of Virginia at
the Virginia Commonwealth University
Richmond, Virginia
PIPC® Goals
• Effectively recognize, diagnose and
treat mental illness in primary care
• Bring the psychiatry skills and
knowledge base of the primary care
physician on par with other medical
specialty knowledge bases
Outline
• PIPC 1
– Introduction
– PIPC Interview
®
– MAPS-O
– Mood Disorders
– Suicide
®
Outline
• PIPC 2
– Anxiety Disorders
• PIPC 3
– Neurotransmitters
– The 3 Phases and the 5Rs
– Medications
– Cases and Discussion
MAPS-O
®
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
Major Depression, Dysthymia,
Bipolar Disorder
MAPS-O®
Mood Disorders
Anxiety Disorders
GAD, Panic Disorder, PTSD,
OCD, Phobias (Social/Specific)
Psychotic Disorders
Substance Abuse
Other
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
Schizophrenia, Schizoaffective
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
Alcohol, Cocaine, Nicotine,
Other Psychoactive Substances
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
“Organic”:
Stroke, Dementia, HIV, TBI
Other Psych:
Personality Disorders, ADHD,
Somatization,Eating Disorders
ANXIETY DISORDERS
Normal vs.
Pathological Anxiety
• A biological warning system that is activated
by perceived danger
• Distressing and usually associated with bodily
discomfort
• Normal levels prepare one for a protective
response
• High levels can be disorganizing, counter–
productive, and cause impairment
• Abnormal when disproportionate to the
potential for harm or when it occurs in
situations reasonably deemed to be harmless
Importance Of Anxiety
Disorders as a Group
• Are the most common mental disorders
– lifetime prevalence for any AD is 24.9%
• Tend to be chronic (more chronic and nonremitting than major depression)
• Have substantial comorbidity
• Carry a burden of distress and impairment
similar to chronic medical disorders
Comorbidity
Comorbidity is the rule
– Depressive disorders (50-70%)
– Substance abuse
– Other anxiety disorders
– Comorbidity predicts:
• chronicity, disability, increased
suicide risk, and poorer treatment
response
Risk Factors
•
•
•
•
Female gender: F:M~2:1 (except OCD M=F)
Family history: Odds ratios 4-6
Trauma (abuse, assault, accidents, etc.)
Stressful Life Events (unemployment, illness,
death of loved one, marital conflict, etc.)
 Note: These are the same risk factors seen in
Major Depression - whenever you consider
someone at increased risk for depression, they
are also at increased risk for an AD
Somatic Symptoms and
Mental Disorders
# of Symptoms
Mood D/O (%)
Anxiety D/O (%)
0-1
2
1
2-3
12
7
4-5
23
13
6-8
44
30
>9
60
48
Medical Mimics of Anxiety
Anxiety Disorder Secondary to …
Substances - Pseudoephedrine, nicotine,
caffeine, marijuana, LSD, cocaine, MDMA
(ecstasy), herbal supplements. Withdrawal of
ETOH, opiates or benzodiazepines.
Medical Disorders – Cardiac arrhythmias (SVT),
congestive heart disease, hyperthyroidism,
vertigo, congenital adrenal hyperplasia,
hypoglycemia, pheochromocytoma,
Medications – Stimulants, theophylline, others.
Anxiety Disorders
•
•
•
•
•
Generalized Anxiety Disorder (GAD)
Panic Disorder
Posttraumatic Stress Disorder (PTSD)
Obsessive Compulsive Disorder (OCD)
Phobias
– Specific
– Social
Anxiety Disorders - Symptoms
“Angst”
Fears
Worry
Increased startle
Restlessness
Easily fatigued
Irritability
Hypervigilence
Muscle tension
Palpitations
Obsessions
Compulsions
Shortness of breath
Choking
Fear of losing control or dying
Difficulty concentrating (“mind goes blank”)
Sleep disturbance (classically initial insomnia)
Generalized Anxiety Disorder
GAD
• Excessive anxiety for 6 months (more days than not)
Difficult to control the worry (a “worrier”)
• Associated with 3 or more of the following:
– Restlessness
– Easily fatigued
– Difficulty concentrating
– Irritability
– Muscle tension
– Sleep disturbance (initial insomnia, fragmented)
Generalized Anxiety Disorder
GAD
• Common, chronic
• Uncontrollable, pervasive anxiety
• Psychological Sx (e.g. excessive worry)
• Somatic Sx (e.g. muscle tension)
• Psychiatric comorbidity common
–Depression
–Other Anxiety Disorders
–Substance Abuse
GAD –
Questions
• Have you frequently been worried or
anxious about a number of things in your
daily life?
–Do people say you worry about things too
much?
–Do you think your anxiety is unrealistic or
excessive?
• Is it hard for you to control or stop your
worrying?
GAD –
Questions
• Now I’m going to ask you about physical
symptoms that often go along with anxiety
and nervousness?
– …feel restless, fidgety, jittery, keyed up
– …get tired easily?
– …feel irritable?
– …feel tension, aches, or soreness in your
muscles
– …have problems falling asleep or staying
asleep
Panic Disorder
• Common, often chronic
• Panic attacks + agoraphobia
• Psychiatric comorbidity common
– Depression
– Other anxiety disorders
– Substance Abuse
• High medical utilization
Panic Attack: 4 or more
Fear of Dying
Sweating
Trembling
SOB
Parathesias
Chest Pain
Fear of Losing Control
Derealization
Nausea
Choking feeling
Hot flashes
Panic –
Medical Presentations
• Cardiac Panic
• Pulmonary Panic
• GI Panic
• Neurological Panic (vertigo)
• Panic exacerbating medical illness
Panic Disorder –
Questions:
• Have you had a sudden rush of intense
feat, anxiety, or discomfort that come on
from out of the blue for no apparent reason
or in situations where you did not expect
them to occur?
• Do you worry a lot about having more of
them?
• Have you changed your behavior since
these attacks began?
Panic Disorder –
Questions:
•
•
•
•
Think back to last attack you had.
When was it?
Where were you at the time?
Would most of the symptoms ever come
on quickly, within ten minutes after the
attack began?
• Did you experience of the following?
– …feel your heart racing, pounding, fluttering,
or skipping beats?
Panic Disorder –
Questions:
– …sweat?
– …tremble or shake?
– …have trouble catching your breath, or feel
like you were being smothered?
– …feel like you were choking?
– …have chest pain, pressure, tightness, or
discomfort?
– …feel nauseated, sick to your stomach, or
like you might have diarrhea?
Panic Disorder –
Questions:
– …feel dizzy, light-headed, unsteady, or like
you might faint?
– …feel like things around you were unreal,
like you were in a dream, like part of your
body were unreal or detached from you…
– …fear you were going crazy or might lose
control?
– …fear you might die?
– …feel numb or tingling in your fingers or
feet?
– …have hot flashes?
Agoraphobia –
Questions
• Some people have very strong fears of
being in certain places or in certain
situations. Do any of the following make
you feel very fearful, anxious or nervous?
– Being away from home?
– Standing in long lines?
– Being in wide open spaces like a park?
Agoraphobia –
Questions
– Being in crowded places like a movie theater,
supermarket, shopping mall, church,
restaurant, etc. ?
– Being on a bridge or in a tunnel?
– Traveling in a bus, train or plane?
– Driving in a car?
– Being home alone?
Agoraphobia –
Questions
• I know it’s difficult to describe, but
what about [ ] that worries you?
• What do think will happen to you?
• What are you afraid of?
Posttraumatic Stress Disorder
PTSD
• Common, following life-threatening,
overwhelming experiences
• Symptom categories:
–Reexperiencing
–Avoidance
–Increased arousal
PTSD – Stressor Criteria
Questions:
• Have you ever seen or experienced a
traumatic event in which your life was
actually in danger or you thought your
life was in danger?
• Have you ever witnessed an event in
which someone else’s life seemed to be
in danger?
• How did you react to the trauma?
– Were frightened or horrified?
– Did you feel helpless and out of control?
PTSD – Re-experiences
Questions:
• Do memories about the [ ] still bother
you?
– Do you see images of the trauma?
– What about dreams?
– What about flashbacks where you relive
the event?
– Are there things that remind you of the [ ]
that get you upset?
– Do the reminders make you tremble, break
you in a sweat, hyperventilate or have a
racing heart?
PTSD – Avoidance
Questions:
• Do you try to block out thoughts or feelings
related to the [ ]?
– Do you try to avoid activities, situations, or places that
remind you of the [ ]?
– Are there aspects of the [ ] that you can’t recall?
– Since the [ ] have you lost interest in some things you
used to enjoy?
– …do you feel distant and cut off from people?
– …have you lost the ability to feel certain emotions?
– Has the [ ] changed how you feel about the future?
PTSD – Hyperarousal
Questions:
• Since the trauma have you…
– ..problems sleeping?
– …more irritable or lost your temper more
easily?
– …problems concentrating?
– …been on the alert, always keeping your guard
up with an eye out for possible trouble?
– ..been kind of jumpy and easily startled by
everyday ordinary noises?
Obsessive Compulsive Disorder
OCD
Obsessions:
persistent ideas, thoughts, impulses, or
images that are experienced as intrusive,
inappropriate, and increase anxiety
Compulsions:
repetitive behaviors or mental acts that are
aimed at preventing or reducing the anxiety
and distress caused by the obsessions
Obsessive Compulsive Disorder
OCD
• Not frequently diagnosed in primary care
setting.
• Patients are often secretive about this
and have increased shame.
• Starts early in life, adolescence or early
adulthood.
OCD –
Questions:
• Some people are bothered by recurrent
thoughts or impulses that seem
inappropriate or do not make sense, but
they keep repeating over and over and are
difficult to get out of your mind.
• Examples: that you are contaminated by
germs; thoughts you might hurt someone
you didn’t want to; that you'd yell
obscenities in public…
OCD –
Questions:
•
•
•
•
•
What about intrusive images?
Describe what it is like?
How often does it happen?
What do you do to deal with this?
Do you try to ignore or get rid of these
thoughts/images and them out of your mind?
• Do you tell yourself things or imagine certain
other images in order to neutralize or
counteract the unpleasant thought or image?
OCD –
Questions:
• Some people are bothered by having to
do something over and over that they
can’t resist when they try. For example:
– Wash hands
– Checking the doors, windows or stove
– Counting things excessively
– …rituals that always have to be in a
particular order, and if the wrong way you
have to start all over again.
Social Phobia
(Social Anxiety Disorder)
•
•
•
•
Common, potentially disabling
Intense fear of embarrassment
Avoidance of social interactions
Rarely recognized in Primary Care
Social Phobia Questions:
• Some people have very strong fears of
being watched or evaluated by others. Do
you worry that you might do or way
something that would embarrass you in
front of others, or that other people might
think badly of you?
• Do you think you are much more anxious
than other people?
• …what about the situation bothers you?
Specific Phobia
• A marked, excessive fear provoked by the
presence or anticipation of a specific object or
situation
• Generally, the phobic object is either avoided or
endured with intense anxiety and distress
• Five subtypes:
1. Animal
2. Natural environment (storms, heights, water)
3. Blood-Injection-Injury (MDs, hospitals, dentists)
4. Situational (public transportation, flying, enclosed spaces)
5. Other (space, loud noises)
Specific Phobia Questions:
• Some people have very strong fears of
certain objects or situations. Such as:
–Heights
–Being near household pets
–Spiders, bugs, snakes, mice or rats
–Seeing blood, getting an injection
–Being in water
–Storms
–Flying in an airplane
Specific Phobia Questions:
• Whenever you are exposed to or even
think of being exposed to [ ] do you
immediately get anxious or nervous?
• Do you think you are more afraid and
worried about [ ] you should be?
• To what degree do you avoid the [ ]?
Health care-related phobias
• Examples of health care-related phobias
– needles
– the sight of blood or open wounds
– pain
– anesthesia
– dental procedures
• Effectively treated with systematic
desensitization
CASE
39 year old woman
• 18 month history of spells where she gets
acutely nauseated, cramping abdominal
pain, sweating and feels light-headed
• She also gets exceedingly scared and
overwhelmed when these occur
• They last 10 minutes on average and are
getting worse
• She is taking Paxil 20 mg with little change
Panic Attacks
• Panic comes as a somatic disorder
– GI, Cardiac, Pulmonary, Vertiginous
• In what disorders can panic attacks
occur?
– Panic d/o, GAD, PTSD, OCD, Phobias,
Major Depression, Substance induced
• What questions help figure out panic?
– Triggered, Phobic avoidance, the “scat”
Panic Attack  Panic Disorder
Diagnosis
Panic
Disorder
Spontaneous Situational
Anticipatory Autonomic Phobic
Arousal
Avoidance
+++
+/-
+++
+++
+
Agoraphobia
+/-
+/-
+++
++
+++
Specific
Phobia
-
++
++
++
+++
Social
Phobia
+/-
+++
++
++
+++
PTSD
+/-
++
+/-
+++
+
GAD
+/-
+/-
+/-
+
+/-
39 year old woman
• Triggered by cars
• Raped 18 months ago in her car at a ATM
(she told no one)
• Had Sx of PTSD
– Reexperiences, Avoidance, Hyperarousal
• Increased EtOH consumption
• Long history of dysthymia
• Trauma in childhood
MAPS-O®
Mood Disorders
Dysthymia
Anxiety Disorders
PTSD* (Panic Attacks)
Psychotic Disorders
Substance Abuse
Other
None
Alcohol (Ab)use
No Organic
Defer “Other Psych”
(Eating d/o, Personality d/o)