GAD and SAD

GAD diagnostic criteria

Excessive or difficult to control anxiety and worry (apprehensive expectation); More days than not for >6 months; Difficult to control/interferes with work or social functioning; Associated with >/ 3 of the following: restlessness/feeling keyed-up, beoing easily fatigued, diffculty concentrating, irritability, muscle tension, sleep disturbance

GAD:somatic symptoms

Trembling, twitching, muscle aches, nausea or diarrhea, sweating, urinary frequency, palpitations, pain

Epidemiology of GAD

12 month prevalence: 2.9% in the US (world is 1.3%); Lifetime morbid risk in the US is 9%; Women to men is 2:1; incidence in european decent is > african or asian; median age of onset is 35; adolescents worry about school performance or competence (sporting events)

Etiology of GAD

Genetics: data is inconsistent, early developmental trauma and recent stressful event - connected ; Neurotransmitter disturbances: Norepi, serotonin, and GABA; Changes in brain metabolism: glucose metabolism in cortex, limbic system, and basal ganglia; Other factors (cognitive, psychological, and developmental): emotional information processing- excessive attention to potentials; Elevated number of traumatic experiences in childhood (ACES)

GAD: Etiology: Biological perspective: Anxiety stimulates the autonomic nervous system, cardiac, respiratory, GI, and musculosckeletal system to cause physical symptoms; Biological factors affecting anxiety manifestations:

Hypothalamic-pituitary adrenal system releases cortisol; corticotropin-releasing hormone; hormones-menstrual cycles, and menopause in wopmen, low testosterone levels in men, thyroid hormones; neurotransmitters

GAD: Etiology: Psychoanalytic perspective

Anxiety signals danger; it is not inherently bad; Rather than try to reduce anxiety, therapy is used to help the client increase tolerance to the symptoms of anxiety; guided by this perspective

Overlapping symptoms of GAD and MDD

Anxiety; Sleep disturbance; Concentration difficulty; Psychomotor agitation; irritability; fatigue

GAD: labs

CBC, CMP, TSH, UA, EKG, UDS

GAD: differentials: Medical

Endocrine: thyroid disease, hypoparathyroidism, hypoglycemia; cushings disease; Autoimmune: graves disease, SLE; Cardio-respiratory: angina, pulmonary embolism; Neurological: seizure disorder, TIAs

GAD: Medications:

SSRIs (escitalopram,. paroxetine, citalopram); SNRIs (venlaxafine, duloxetine); Buspirone (augment SSRI with this); Gabapentin (recommended by uptodate if suboptimal response to SSRI plus buspar); Antipsychotics: atypicals (adjunct) but can be used as monotherapy; Hydroxyzine, pregabalin, bupropion, kava, lavendar oil; Benzodiazepnines: longer lasting- use after many other failures

Long term treatment of GAD

Need to treat long-term (>12 months); Around 25% of patients relapse within 1 month of stopping treatment; 60-80% relapse within first year after stopping treatment

GAD with coexisting MDD

Increased treatmen resistance or delayed response; increased suicidal behavior; antidepressants are indicated if depression is moderately severe or severe; CBT and interpersonal therapy

DSM 5 Social Anxiety Disorder

§DSM-5-TR:

–Fear or anxiety about >=1 social situations (Having a conversation, meeting new people, being observed, speech)

–Fears they will act in a way or show anxiety that will be negatively evaluated

–Situations almost always provoke fear and anxiety

–Avoidance of situations or endured with intense fear

–Fear is out of proportion

–Persistent and lasting for more than 6 months

–Not caused by another disorder or medical condition

DSM 5 SAD subtype characteristics: Generalized

~70%; pervasive social fears, avoidance; Early onset; Familial; >80% comorbidity; More impiarment; Lower remission rare; extended treatment needed

DSM 5 SAD subtype characteristics: Performance only

~30%; many social fears; mostly affects professional lives; later onset; not familial; less comorbidity; limited impairment; remission common; PRN treatment usually adequate

Social Anxiety Disorder Symptoms: physical

Tachycardia, trembling, blushing, shortness of breath, sweating, abdominal distress, socially cued panic attacks

Social Anxiety Disorder Symptoms: Cognitive

Perceived scrutiny and certainty of negative evaluation; Misinterpretation or failure to note social cues

Social Anxiety Disorder Symptoms: Behavioral

Avoidance; Freezing

Epidemiology of SAD

5-12% (lifetime); prevalence decreases with age; higher in american indians; lower in asian, latino, and african americans

SAD course of illness

Median age of onset is 13 years; some have a history of being shy; may follow a stressful or humiliating experience; may diminish or re-emerge

SAD related impairment

Lower educational status (are less likely to graduate high school, work in less skilled occupations); Lower income and socioeconomic status; lower likelihood of marrying; higher likelihood of divoce; impeded leisure activities

SAD differential diagnosis

Avoidant personality disorder; Panic disorder/agoraphobia; Generalized anxiety disorder; Depression-related social avoidance; Separation anxiety disorder; Body dysmorphic disorder; Schizotypal/Shizoid personality disorer; medical conditions (like a a tumor)

When SAD occurs in other disorders

SAD is diagnosed in patients with major depression if the social anxiety persists after depression remits. In OCD, the social anxiety reflects a concern that others will notice the obsessing or the compulsions. In Panic disorder, at least some attacks occur unrelated to social situations. In autism spectrum disorder, social awkwardness and social communication and language deficits are evident

Screening for Generalized Social Anxiety: Mini Social Phobis Inventory

Three items about avoidance and fear of embarrassment that you rate based on the past week. 1. Fear of embarassment causes me to avoid doing thing or speaking to people 2. I avoid activities in which I am the center of attention 4. Being embarassed or looking stupid are among my worst fears. Rated 0-4. Score of 6 is the cutoff for possible problems with social anxiety

Treatment of SAD: NICE guidelines

CBT (usually not group); SSRI (escitalopram or sertraline); SNRI; Possible a MAOI

Overall Anxiety: MSE

Behavior: restless, fidgety, pacing, sweating/diaphoretic; Eye contact: may be intense, or may be minimal, assess for pupil size; Speech: may be pressured, rapid, incoherent, Concentration: inattentive, distracted; Mood: Using their own words and place that in quotes in your note “im terrified” Affect: Anxious or worried, may appear tense, worried, stressed, restless, quiet, starlted, guarded

Anxiety: Mental Status Exam

Thought process: can be organized, goal directed, circumstantial; Thought content: usually no perceptual changes such as AVH, paranoia, or deulsional content; judgement: will vary based on patient; Insight: will vary based on patient; Memory: impaired short term and immediate, forgetful

Overall anxiety: Follow up

See client weekly or at least every two weeks to assess respons eto rx and adjust; teaching should include risks, benefits, side effects of medication; if taking benzozs, monitor for depenence; If ssri monitor for side effects, adverse effects; Teach symptoms of anxiety and chronic nature of anxiety, help client plan for relapse; Assess for suicidality especially if symptoms exacerbated— especially in adult males with extreme restlessness/agitation; Evaluate for depression due to very high co-morbidity

Sleep Disturbance/Insomnia

Multiple contributing causes; Some treatments may result in worsening insomnia (SSRIs and SNRIs); More sedating agents like hydroxyzine and prebablin (not approved in US for GAD) may be preferred over SSRIs and SNRIs; Add trazodone to SSRI; Add benzodiazepines but may cause rebound effects the night after stopping

Elderly considerations

SSRIs (sertraline or escitalopram): gait impairment, gi bleeds, bone loss, low sodium; SNRIs (venlaxafine) raise blood pressure at 200 mg; Pregabalin: sleepiness, dizziness, and falls with fracture; Benzos: falls, decreased RR, auto accidents, abuse, sedation; Quetiapine: metabolic risks and QTc raises

Women of child bearing potential and who may become pregnant during treatment

Benzos: category D rating for pregnancy due to cleft palate risk; SSRIs and SNRIs: all category C rating except for Paroxetine (category D due to atrial septal defects; SSRIs may affect risks of postpartum hemorrhage, premature delivery, and other postnatal complications

Nightmares

Prazosin; add on. Also helps with daytime symptoms of PTSD

Bipolar Depression

Rates of GAD are higher in bipolar compared with unipolar depression; Antidepressants normally good for GAD such as SSRIs not recommended in bipolar rapid cyclers