Transcript The Anxiety Disorders Some Practical Questions & Answers

The Anxious Patient
A Patient-Centered, Evidence-Based Diagnostic
and Treatment Process1,2
A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPA
March 18, 2011
1 This
is problem-oriented learning with numerous links to supporting resource material.
let me know how I can improve my service to you on your evaluation, in person or on Facebook.
2 Please
Why should you learn about these
disorders?
• They are the most common mental disorders.
• These disorders are frequently missed, ignored or
mistreated.
• These disorders cause substantial distress and
impairment.1
• Patients with these disorders over-utilize other
medical services.2,3
• Many physicians still lump these disorders and
minimize them as “nerves.”
• These disorders can usually be effectively treated.
1 Significant
distress and/or impairment are required to make a psychiatric diagnosis.
and depression are frequently masked by physical complaints.
3 One of my elderly patients never talked about her anxiety, only the “burning in my head.”
2 Anxiety
What are some of the physical
manifestations of anxiety?
• Diarrhea
• Dizziness or lightheadedness
• Hyperhidrosis
• Hyperreflexia
• Hypertension
• Palpitations
• Pupillary mydriasis
1 Most
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Restlessness
Syncope
Tachycardia
Tingling in the
extremities
• Tremors1,2,3
• Upset stomach
(“butterflies”)
• Urinary frequency,
hesitancy, urgency
tremors are worsened by anxiety.
admitted a man from the ED who developed a significant conduction disturbance.
3 I unexpectedly experienced panic when undergoing MR imaging.
2I
What are some of the mental
manifestations of anxiety?
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1 Anxious
2 One
Apprehension
Vigilance
Scanning
Shame
Confusion
Distortion of perception
Decreased concentration
Poor recall
Impaired association
Selective inattention
False assumption1,2
patients always assume the worst.
of my patients noted, “You don’t look so good.”
What is a clinical decision tree for
diagnosing the anxiety disorders?
Anxiety
“Normal”
Anxiety
Anxiety
Disorders
Anxiety 2o to
Gen Med Cond
SubstanceInduced
Anxiety
Anxiety Assoc
With Another
Mental Disorder
Panic Disorder
Agoraphobia
Specific Phobia
COPD
Sedatives
Social Phobia
Pulmonary Embolism
Anesthetics
OCD
CHF
Stimulants
PTSD
Hypothyroidism
Alcohol
Adjustment Disorders
Acute Stress Disorder
Etc.
Gen Anxiety Disorder
Hypoglycemia
Etc.
Caffeine
Etc.
1 These
Dissociative Disorder
Cognitive Disorder
Mood Disorder
Etc.
categories form an excellent conceptual algorithm for evaluating psychiatric symptoms in clinical
practice.
What is the difference between
normal and pathologic anxiety?
• It is often impossible to tell.
• Whether the anxiety or fear promotes
adaptation or causes impairment must be
considered.
• Whether a given distress is judged normal or
pathologic depends on one’s resources,
psychological defenses, and coping
mechanisms.1,2
• “Is this more than the usual ups and downs of
life?” will often point the physician in the right
direction.
1 Strong
emotion of any sort impairs your ability to think clearly and act rationally.
of my patients came out of the restroom to find the atrium door locked. The sign on my door may
have discouraged potential rescuers. All she needed to do was turn the deadbolt and walk out.
2 One
What specific diagnoses are included
in this category?
• Panic disorder without
agoraphobia
• Panic disorder with
agoraphobia
• Agoraphobia without a
history with panic
disorder
• Specific phobia
• Social phobia
• Obsessive-compulsive
disorder
1 Always
remember to ask about caffeine.
• Posttraumatic stress
disorder
• Acute stress disorder
• Generalized anxiety
disorder
• Anxiety disorder due
to a [GMC]
• Anxiety disorder NOS1
What is the epidemiology of anxiety?
• This in one of the most
common groups of
psychiatric disorders.
• One in four persons has
diagnosable anxiety
disorder.
• The 12-month
prevalence rate is
17.7%.
• The prevalence of these
disorders decreases with
higher socioeconomic
status.
Lifetime Prevalence
of Anxiety Disorder
35%
30%
25%
20%
15%
10%
5%
0%
Men
Women
What is the biological basis of
anxiety?1,2
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Autonomic Nervous System
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Neurotransmitters
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Some genetic component clearly contributes to the
development of anxiety disorders.
Neuroanatomical Considerations
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Some patients with anxiety disorders have functional or
anatomical changes.
Genetic Studies
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Norepinephrine
Serotonin
γ- aminobutyric acid (GABA)
Brain-Imaging Studies
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Increased sympathetic tone in anxious patients
The locus ceruleus and raphe nuclei project to the limbic
system.
The limbic system contains a high concentration of
GABAA receptors.
The frontal cerebral cortex is connected with the
parahippocampal region, the cingulate gyrus, and the
hypothalamus.
Kaplan & Sadock, 2008
observations are true for all of the anxiety disorders.
2These
What about anxiety due to another
medical condition?
• Anxiety commonly
accompanies many different
general medical conditions.
• These underlying conditions
cause anxiety via the
noradrenergic and perhaps
the serotonergic systems.
• Paroxysmal bouts of anxiety
should make clinicians
suspicious.
• The clinical features can be
identical to those of the
primary anxiety disorders.
1 If
• Primary anxiety disorders
generally have their onset
before age 35.
• Anxiety symptoms may
persist after the primary
disorder is treated.
• The underlying disorder
should be treated first, but
the anxiety may need to be
addressed separately.1,2
you decide up front that the patient is a crock, this will set you up for some serious mistakes.
of my “crock” patients presented to the ED with the history of a dilated pupil.
2 One
What about substance-induced
anxiety disorders?
• This is a common
consequence of recreational
and prescription drug abuse.
• You must think about it and
ask about it every time.
• Don’t forget about caffeine.
• The associated clinical
features may vary with the
substance involved.1,2
• Cognitive impairments in
comprehension, calculation
and memory usually
disappear when the
substance is discontinued.
1 People
2I
• The differential diagnosis
includes
– Primary anxiety disorders
– Anxiety due a general
medical condition (for which
the patient may be receiving
the implicated drug)
– Mood disorders
– Personality disorders
– Malingering
• Removal of the offending
substance is the preferred
treatment
who take a lot of speed become overtly paranoid.
evaluated a patient at a MHC who was convinced that the FBI was landing UFOs in his backyard.
What about mixed anxietydepressive disorder?
• These are patients that don’t
meet full criteria for either a
mood or an anxiety disorder.
• They are particularly
common in primary care
practices.
• On careful examination, they
often are depressed. The
accompanying anxiety is
misleading.
• For this reason, the
syndrome is controversial.
1 These
2 When
• This combination of
symptoms leads to
considerable functional
impairment.
• Up to 2/3 of depressed
persons are also anxious and
up to 9/10 of panic patients
experience depression.
• If this emerges as a specific
diagnosis, it may affect about
1% of the population.
• The serotonergic drugs are
helpful for both the anxiety
and depression.1,2
“mixed syndromes” can be very challenging. Unfortunately, few of your patients will have read the book.
in doubt, treat for depression. It is very hard to get patients off benzodiazepines.
Where can you learn more?
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1,2Please
American Psychiatric Association, Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical
Psychiatry, Third Edition, 20081
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of
Neurology, April 20072
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry
Clerkship, Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and
Review, Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the
Brain, January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving
at Home, Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
note that you must master all of the information in a basic neurology textbook and a basic psychiatry
textbook to do well on the comprehensive, standardized final examination.
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties
of your choice here.
Subscribe to Evidence-Based Mental Health and search a database at
the National Registry of Evidence-Based Programs and Practices
maintained by the Substance Abuse and Mental Health Services
Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Carolyn Arnett, DO
OUCOM 1993
www.somc.org
Jason Cheatham, DO
OUCOM 2002
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