Generalized Anxiety Disorders (GAD) & Panic Disorder

Generalized Anxiety Disorder (GAD)

A serious chronic mental health condition characterized by excessive, persistent, and uncontrollable worry about a variety of daily events and activities

• a lifetime prevalence of 4.3-5.9%.

• Only two out of five receive appropriate treatment

Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR)

diagnosing mental health conditions in the United States

Generalized Anxiety Disorder (GAD) DSM 5 Diagnosis

• Excessive anxiety and worry occurring more days than not for at least 6 months about several events or activities.

• Anxiety or worry is difficult to control.

• The worries are difficult to control and must be associated with at least three of the following:

1. Restlessness of feeling keyed up or on edge

2. Being easily fatigued

3. Difficulty concentrating or mind going blank

4. Irritability

5. Muscle tension

6. Sleep disturbance  

• Clinically significant distress or impairment in social, occupational, or other important areas of function.

• Not attributable to substance or medical condition.

• Not better explained by another mental health disorder

GAD-7 Screening Tool

• validated diagnostic tool and severity assessment

• Scores range from 0–21

• A score of 10 or more has good diagnostic sensitivity and sensitivity

• Higher scores correlate with more functional impairment.

Panic Disorder

• Episodes of unexpected panic attacks that occur without a clear trigger.

• Defined by a rapid onset of intense fear (about 10 minutes).

• A patient can also have a panic attack with a known trigger, although unexpected panic attacks are required for diagnosis.

Panic Disorder Diagnosis

based on at least four physical and psychological symptoms in the DSM-5 diagnostic criteria on the right

Panic Disorder Psychological Signs & Symptoms

Excessive & uncontrollable worry
• Persistent, out of proportion worry on most days.
Difficulty concentrating

• Mind goes blank, inability to stay focused.

Feeling overwhelmed or out of control

• Sense of impending doom, trouble making decisions.

Irritability

• Low frustration tolerance. Heightened sensitivity to stressors.

Restlessness
• Feeling on edge. Racing thoughts.

Negative self-talk
• What if thinking. Underestimating coping ability.
Impaired functioning

• Difficulty completing tasks. Reduced productivity.

Anticipatory anxiety

• Constant expectation that something bad will happen.

Panic Disorder Physical Signs & Symptoms

Neurological

• Tremors or shakiness

• Headaches

• Lightheadedness or dizziness

• Sleep disturbances

Cardiovascular

• Tachycardia

• Palpitations

• Chest tightness or discomfort

• Increased blood pressure

Respiratory
• Shortness of breath

• Hyperventilation
• Air hunger (respiratory alkalosis)

Gastrointestinal
• Nausea/ vomiting
• Diarrhea or loose stools
• Abdominal discomfort
• Irritable bowel-like symptoms—-loss of appetite or overeating

Musculoskeletal

• Muscle tension

• Muscle aches or soreness

Jaw clenching

Genitourinary

• Increased urinary frequency

• Fertility problems

• Missed periods

• Low sex drive

• Erectile dysfunction

Integumentary

• Sweating

• Cold, clammy skin

• Dry mouth

Endocrine/Metabolic

• Fatigue

• Increased cortisol release

• High blood sugar
• Appetite changes
• Weakened immune system

Cognitive Behavioral Therapy – Problem-Oriented

• Cognitive portion to change thinking patterns that support fears.

• Behavioral portion to train patients to relax deeply and desensitize patients to anxiety provoking triggers.

Cognitive Behavioral Therapy Goal

recognize, eliminate, and correct anxiety provoking assumptions and thoughts

Cognitive Behavioral Therapy - Exposure Therapy

• helps to overcome fears, phobias, and trauma through gradual exposure.

• Avoidance keeps anxiety strong, while exposure helps the brain to learn the stimulus is safe or tolerable

• Involves exposing someone in a safe environment, to the object, activity, or situation that they fear or struggle

1st Line: Selective Serotonin Reuptake Inhibitors (SSRIs) [Setraline (Zoloft), Escitalopram (Lexapro)] Mechanism of Action

• block the reuptake of serotonin by inhibiting the serotonin reuptake transporter at the presynaptic neuron.

• Increased serotonin concentration in the synaptic cleft.

• Enhanced and prolonged serotonin signaling.

1st Line: Selective Serotonin Reuptake Inhibitors (SSRIs) Effect

• Improved regulation of mood, anxiety, and emotional processing.

• Takes 4-6 weeks for full effect.

• Must be tapered off to limit relapse

Serotonin Syndrome

A life-threatening condition associated with increased serotonergic activity. It is seen with SSRI use.

• diagnosed without lab values or tests—through assessment

Serotonin Syndrome Signs and Symptoms

• Hyperthermia

• Agitation

• Reflexes(hyperreflexia+clonus– rhythmic involuntary contraction)

• Mydriasis(dilation of the pupil)

• Elevated Heart Rate

• Diarrhea

Augmentation: Benzodiazepines [Lorazepam (Ativan), Alprazolam (Xanax), Diazepam (Valium)]

• Effective in reducing anxiety,but associated with tolerance, sedation, and confusion

• “Should” only be used short term

• The result is sedative,anxiolytic (anti-anxiety), and anticonvulsant (anti-seizure).

• Overdoses are possible

Benzodiazepines [Lorazepam (Ativan), Alprazolam (Xanax), Diazepam (Valium)] Mechanism of Action

Enhances the effect of GABA,the main inhibitory neurotransmitter, causing CNS depression.

Benzodiazepine Overdose

Central Nervous System Depression:

• Slurred speech

• Ataxia (poor muscle control &

  balance)

• Altered mental status

• Decreased consciousness

Respiratory depression

Hypotension (inability to control autonomic nervous system)

Reversal Agent for Benzodiazepine Overdose

Flumazenil: Competitive receptor antagonist of the GABA-A receptor

Serotonin

neurotransmitting regulate mood, behavior, sleep, appetite, and digestion

Relapse after abruptly stopping SSRIs

may cause sudden reoccurrence of previous symptoms—-also causing GI issues, balance problems, flu-like symptoms, sleep disturbances, and cognitive changes

GABA

primary inhibitory neurotransmitter in the brain, which means it blocks or reduces nerve cell activity, helping to calm the nervous system and promote relaxation