BH 2 Anxiety disorders

Generalized Anxiety Disorder (GAD)

Excessive anxiety and worry about several events or activities; intensity, duration, or frequency is out of proportion to the actual likelihood or impact of the anticipated event.

GAD

At least three of:

feeling restless/keyed-up/on edge

easily fatigued

difficulty concentrating or mind going blank

irritability

muscle tension

disturbed sleep

Unknown.

GAD — exact cause

Minor life stressors, physical or emotional trauma, and genetic factors contribute.

GAD — contributing factors

One-third of cases are linked to a genetic factor.

GAD — genetic association

2:1.

GAD — female-to-male ratio

Over half of patients seeking help have onset in childhood or adolescence.

GAD — onset

Almost half of patients retain the diagnosis over 2 years after diagnosis.

GAD — persistence

Shakiness, restlessness, headaches, muscle aches or soreness.

GAD — motor tension symptoms

SOB, excessive sweating, palpitations, and GI complaints.

GAD — autonomic hyperactivity symptoms

Inability to concentrate on anything other than anxiety (impaired cognitive vigilance), irritability, easily startled, and dizziness.

GAD — cognitive symptoms

Excessive anxiety and worry, occurring more days than not, for at least 6 months, about a number of events or activities w/ inability to control the worry

GAD DSM-5 — core duration criterion

Anxiety and worry are associated with at least 3 of 6 symptoms, with at least some symptoms present more days than not for the last 6 months; only 1 item is required in children.

GAD DSM-5 — symptom criterion

1) Restlessness/keyed up/on edge

2) easily fatigued

3) difficulty concentrating or mind going blank

4) irritability

5) muscle tension

6) sleep disturbance.

GAD DSM-5 — six symptoms

Anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

GAD DSM-5 — impairment criterion

The disturbance is not due to the direct physiological effects of a substance or another medical condition - not better explained by another mental health disorder

GAD DSM-5 — substance/medical criterion

Cognitive/behavioral therapies and pharmacotherapy

GAD — treatment modalities

SSRIs.

GAD — pharmacotherapy first line

6-12 months to lifelong

GAD — treatment duration

Benzodiazepines

What other medication can be used as a short-term adjunct medication for GAD?

SNRIs

GAD — alternative medication class (second line)

Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro).

GAD — SSRI first-line drugs

6-8 weeks.

SSRIs — onset of full therapeutic potential

Highly individual and drug specific.

SSRIs — side effects

Suicidal thoughts and behaviors in children, adolescents, and young adults - 25 and younger

SSRIs — black box warning

Sexual dysfunction, drowsiness, nausea/vomiting/diarrhea, discontinuation syndrome.

SSRIs — most common adverse effects

Midazolam (Versed)

Short-acting benzodiazepine

Temazepam (Restoril)

alprazolam (Xanax)

lorazepam (Ativan)

Intermediate-acting benzodiazepine

Clonazepam (Klonopin), diazepam (Valium) *prescribed more frequently for GAD*

Long-acting benzodiazepines

Venlafaxine (Effexor), desvenlafaxine (Pristiq), duloxetine (Cymbalta), levomilnacipran (Fetzima).

GAD — SNRI medication list

Amitriptyline

most common TCA used for GAD

They are used less often due to side effects.

TCAs — why used less often in GAD

buspirone (BuSpar)

Most common Anxiolytic used to treat GAD

Antihistamines such as hydroxyzine and beta-blockers such as metoprolol.

GAD — other medications used for tx

prognosis is difficult to predict because GAD most often occurs concomitantly with other mental health disorders.

GAD — prognosis

Panic Disorder

An acute intense attack of anxiety accompanied by feelings of impending doom.

Neurotransmitter dysfunction

possible s/e to some medications

Genetic component

Panic Disorder — etiology/cause

First-degree relatives of patients with panic disorder have a 4-8-fold higher risk.

Panic Disorder — family risk

Up to 65% of patients have at least one other psychiatric illness.

Panic Disorder — psychiatric comorbidity

- Sexual and/or physical abuse history

- divorce or separation

Panic Disorder — risk factors

20-24 years.

Panic Disorder — mean age of presentation

Women are 2-3 times more likely to be affected than men.

Panic Disorder — sex difference

Panic Disorder

Symptoms:
Extreme fear

sense of impending death/doom

tachycardia

palpitations

dyspnea

sweating

rumination

difficulty speaking

impaired memory

20-30 minutes; rarely more than 1 hour.

Panic attack — typical duration

Deep in thought; lost in thought.

Rumination definition

Panic Disorder

An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, with at least 4 associated symptoms.

Panic attack DSM-5 — symptom list

Palpitations, pounding heart, or accelerated heart rate

sweating

trembling or shaking

SOB or smothering

choking sensation

CP or discomfort

Dizziness, unsteadiness, lightheaded or faint

chills or heat sensations

paresthesias

derealization and/or depersonalization

fear of losing control or going crazy

fear of dying

At least one attack is followed by 1 month or more of 1 of the following:

1) persistent concern about additional attacks

2) consequences and/or a significant maladaptive change in behavior related to the attacks.

Panic Disorder DSM-5 — 1-month criterion

The disturbance is not attributable to the physiological effects of a substance or another medical condition or not better explained by another mental disorder.

Panic Disorder DSM-5 — substance/medical criterion

SSRIs + therapy

Panic Disorder — first-line medication and tx

Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro).

Panic Disorder — SSRIs listed

benzodiazepines

What alternative medications can be used for adjunct/acute symptoms in panic disorder?

short and intermediate acting:

Midazolam (Versed), alprazolam (Xanax), lorazepam (Ativan)

Panic Disorder — common benzodiazepines used

SNRIs, TCAs, and buspirone (BuSpar)

Panic Disorder — second/third line medication therapies used

Cognitive/Behavioral Therapy.

Panic Disorder — psychotherapy

Focuses on examining relationships between thoughts, feelings, and behaviors; helps modify thinking to improve coping.

CBT

Starting doses can be titrated to efficiency, side effects, or maximum dose, whichever comes first.

SSRIs — titration principle in panic treatment

Short-term, PRN use if possible because of habituation potential and withdrawal, which can occur after just 2 weeks of use.

Panic Disorder — benzodiazepine duration/use

Midazolam, alprazolam, and lorazepam can be administered IM, IV, or PO.

Panic Disorder — benzodiazepine routes

Phobias

An excessive fear of a specific object, circumstance, or situation.

avoidance behavior.

Typical behavior associated with phobias

Variable; genetics and environmental factors.

Phobias — etiology

50-80% of patients with phobias have another mental disorder.

Phobias — comorbidity/risk factor

Parental overprotectiveness, parental loss and separation, and physical and sexual abuse.

Phobias — environmental risk factors

7-12%.

Phobias — adult prevalence

More common in females than males.

Specific phobia — sex prevalence

Often develops after a traumatic event, observation of others going through a traumatic event, or an unexpected panic attack during exposure to the situation/object.

Specific phobia — development

5-13 years old.

Specific phobia — age of onset

13-21 years old.

Social phobia — age of onset

exposure to the stimulus, anticipation of the stimulus, or hearing the name of the stimulus spoken aloud.

Phobias — symptom trigger

Panic, dread, horror, or terror.

Phobias — emotional symptoms

Recognition that the fear goes beyond normal boundaries and the actual threat of danger.

What do patients who struggle with phobia recognize/admit?

Reactions are automatic and uncontrollable, practically taking over the person's thoughts.

Phobias — reaction quality

Rapid heartbeat, shortness of breath, trembling, and an overwhelming desire to flee.

Phobias — physical symptoms

Extreme measures may be taken to avoid the feared object or situation.

Phobias — avoidance

Fear is the normal response to a genuine danger; with phobias, the fear is irrational or excessive and may be an abnormally fearful response to an imagined danger or an irrationally exaggerated danger.

Normal fear vs phobia

Social phobia

Excessive fears of scrutiny, embarrassment, and humiliation in social or performance situations, leading to significant distress or impairment in functioning.

Female gender, FHx, and early childhood shyness or behaviorally inhibited temperament.

Social phobia — risk factors

Behaviorally inhibited temperament

Consistent demonstration of a behavioral style that is restrained, wary, and fearful in response to unfamiliar stimuli, both social and non-social.

Rigid body posture, inadequate eye contact, overly soft voice, shy or withdrawn behavior, and seeking employment with little social interaction.

Social phobia — behaviors

Marked fear or anxiety of one or more social situations in which the individual is exposed to possible scrutiny by others, including social interactions, being observed, and performing in front of others.

Social phobia DSM-5 — fear criterion

The individual fears acting in a way or showing anxiety symptoms that will be negatively evaluated.

Social phobia DSM-5 — feared evaluation

Social situations almost always provoke fear or anxiety.

Social phobia DSM-5 — provocation

Social situations are avoided or endured with intense fear or anxiety.

Social phobia DSM-5 — avoidance

Fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

Social phobia DSM-5 — proportionality

Fear, anxiety, or avoidance is persistent, typically lasting 6 months or more.

Social phobia DSM-5 — duration

Fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Social phobia DSM-5 — impairment

Fear, anxiety, or avoidance is not attributable to the physiological effects of a substance.

Social phobia DSM-5 — substance criterion

Not better explained by another mental disorder such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

Social phobia DSM-5 — differential mental disorder criterion

If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Social phobia DSM-5 — medical condition criterion

Specific phobia

Clinically significant fear of a particular object or situation that typically leads to avoidance behavior.

Usually has onset in childhood.

Specific phobia — natural environment onset

Usually has onset in the mid-20s.

Specific phobia — situational onset

Marked fear or anxiety about a specific object or situation.

Specific phobia DSM-5 — criterion 1

The phobic object or situation almost always provokes immediate fear or anxiety.

Specific phobia DSM-5 — criterion 2

The phobic object or situation is actively avoided or endured with intense fear or anxiety.

Specific phobia DSM-5 — criterion 3

Fear or anxiety is out of proportion to the actual danger posed by the object/situation and to the sociocultural context.

Specific phobia DSM-5 — criterion 4

Fear, anxiety, or avoidance is persistent, typically lasting 6 months or more.

Specific phobia DSM-5 — minimum duration

Fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specific phobia DSM-5 — criterion 6

The disturbance is not better explained by symptoms of another mental disorder, including fear/anxiety/avoidance associated with panic-like or other incapacitating symptoms; obsessions; traumatic-event reminders; separation from home or attachment figures; or social situations.

Specific phobia DSM-5 — criterion 7