Anxiety Disorders

Case 10: A 30 year old male pharmacist complains of a lifelong history of excessive worry, worse over the past year as he has had more responsibility at work and he and his wife have had their first child. He is constantly worried that something will go wrong at work, that he will be fired, or that something will happen to his baby, even though he realizes that he has no reason to be worried. He complains of muscle tension, feeling exhausted by worry, upset stomach, and irritability. *Which medication would you prescribe for him?* 1.) Buspirone 2.) Bupropion 3.) Clonazepam 4.) Alprazolam 5.) Imipramine

*1.) Buspirone = first med for GAD*

Case 9 Cont: The patient tells you that she is happy to try this medication, but that she is avoiding basic activities (e.g. going to the grocery store) and has been too fearful to go to work. She feels she needs something to help her function as soon as possible. You decide to prescribe an adjunctive medication. *What adjunctive medication would you prescribe?* 1.) Clonazepam 2.) Bupropion 3.) Buspirone 4.) Quetiapine

*1.) Clonazepam* - Benzo, good for acute anxiety, fast acting = helps right away

A diagnosis to consider in evaluating patients presenting with severe anxiety is: 1.) Hyperthyroidism 2.) Hypocortisolemia 3.) Hypocalcemia 4.) Hypernatremia 5.) Hyper-parathyroidism

*1.) Hyperthyroidism* - Hypocortisolemia may be associated w/ increased anxiety but is uncommon

Tolerance refers to: 1.) Lack of side effects 2.) Needing a higher dose to get the same effect 3.) Having withdrawal symptoms with discontinuation 4.) Being willing to prescribe benzodiazepines

*2.) Needing a higher dose to get the same effect

Benzodiazepines

*Clinical Effects*: - Anxiolysis - Sedation/hypnosis - Anticonvulsant - Muscle relaxant *Side Effects* - Sedation - Psychomotor impairment (driving) - Anterograde amnesia - Release of punishment-suppressed behavior (disinhibition) - Tolerance, dependence, withdrawal - Abuse potential

Case 3: A 15 year old Korean American boy is brought in by his parents because for the past 3 months he has been washing his hands over 50 times a day, so that his hands are red and chapped. His teachers complain that he leaves class frequently to go and wash his hands. He seems distracted during the visit with you and looks up at the ceiling repeatedly. When you ask him why, he says that otherwise he fears the ceiling will fall down, even though he knows rationally that this won't happen. He has a history of motor tics. *What is the most likely diagnosis?* 1.) GAD 2.) OCD 3.) Tourette's disorder 4.) Schizophrenia 5.) Specific phobia

*2.) OCD*

Case 9: A 25 year old woman has just moved to Seattle last summer to start a PhD program in Biochemistry. She comes to see you because she now has a 6-month history of constant anxiety and panic attacks 3-4 times per week. She has no history of prior psychiatric problems or treatment, denies medical problems, is on no regular medications, drinks about 4 drinks per week, and denies a history of substance abuse or dependence. *What is the best medication to prescribe for her?* 1.) Clonazepam 2.) Sertraline 3.) Buspirone 4.) Bupropion

*2.) Sertraline* ALL can be used, but Sertraline would be the first choice - Buproprion can cause initial increase in anxiety

Case 2: A 30 year old white male pharmacist complains of a lifelong history of excessive worry, worse over the past year as he has had more responsibility at work and he and his wife have had their first child. He is constantly worried that something will go wrong at work, that he will be fired, or that something will happen to his baby, even though he realizes that he has no reason to be worried. He complains of muscle tension, feeling exhausted by worry, upset stomach, and irritability. *What is the most likely diagnosis?* 1.) Panic disorder 2.) Social anxiety disorder 3.) Generalized anxiety disorder (GAD) 4.) Obsessive compulsive disorder (OCD) 5.) None of the above

*3.) Generalized anxiety disorder (GAD)*

Case 5: A 38 year old single white female graphic designer complains of a long history of anxiety attacks that interfere with her work. In meetings, or whenever she has to give presentations, she becomes terrified, has a pounding heart, dizziness, sweating, shaking, and her mind "going blank", and often has to leave the room. She works as a consultant and has turned down permanent jobs and promotions because of her fear of regular meetings or presentations. *What is the most likely diagnosis?* 1.) Panic disorder 2.) GAD 3.) Social anxiety disorder 4.) PTSD 5.) Specific phobia

*3.) Social anxiety disorder

A critical feature of panic disorder is what? 1.) generalized anxiety around many issues in life 2.) fear of social situations 3.) fear of having another panic attack 4.) fear of being trapped where help is not available 5.) being invariably linked to comorbid medical problems

*3.) fear of having another panic attack*

Case 4: A 25 year old single female Caucasian cashier at a grocery store was involved in a robbery at the store 2 months ago. She was held at gunpoint, with 5 co-workers, for several hours. She was unharmed, but shaken. She has nightmares every night about this event, thinks about it repeatedly during the day, and startles and feels panicky whenever someone resembling the robber enters the store. She feels on edge, very anxious, and depressed, and has withdrawn from her friends and family. *The most likely diagnosis is:* 1.) Major depression 2.) Specific phobia 3.) GAD 4.) PTSD 5.) Acute stress disorder

*4.) PTSD* (over 1 month)*

Case 7: A 28 year old single unemployed Caucasian woman comes in complaining of depression. She lives at home with her parents, only socializes with their friends, and rarely leaves the house. She describes feeling fearful coming to see you. She has been unable to work because she is so intimidated by and afraid of other people. You treat her for depression and her mood improves. You start therapy for social anxiety disorder and take her on a walk around the hospital to have her describe her thoughts about other people. She thinks people in the hospital are looking at her, talking about her behind her back, want to hurt her, and might come up behind her and grab her. *The most likely explanation of her fear of other people is:* 1.) Depression 2.) Social anxiety disorder 3.) PTSD 4.) Paranoia 5.) Unfriendly hospital staff

*4.) Paranoia* - often presents like social anxiety!

*Which medical condition would be a contraindication for this medication?* 1.) Diabetes mellitus 2.) Hypertension 3.) Hypothyroidism 4.) Sleep apnea 5.) None of the above

*4.) Sleep apnea - problem with respiratory drive, which is supressed by Clonazepam*

*Benzodiazepine side effects include:* 1.) Dependence and withdrawal 2.) Sedation 3.) Anterograde amnesia 4.) Psychomotor impairment 5.) All of the above

*5.) All of the above*

Case 1: A 28 yo married Hispanic woman from South Texas moved to Seattle 6 months ago because of her husband's job. She is employed as a hair stylist. Last week, at work, she suddenly felt frightened "out of the blue", with heart racing, sweating, shaking, dizziness, nausea, and a feeling that something bad was going to happen. She had to go outside for 15 minutes until the symptoms went away. She had a similar episode yesterday and comes in alarmed that something is "really wrong" with her. *Her symptoms are best characterized as:* 1.) Agoraphobia 2.) Panic disorder 3.) Post-traumatic stress disorder (PTSD) 4.) Specific phobia 5.) Panic attacks

*5.) Panic attacks*

Benzodiazepines for Anxiety:

*Alprazolam* (Xanax): Fast onset, high abuse potential *Lorazepam* (Ativan): Oral, IV, and IM, No active metabolites *Clonazepam* (Klonopin): Less abuse potential, used with BZD tapers *Diazepam* (Valium): Longer acting but also fast onset Clonazepam and Diazepam = Long Acting Alprazolam and Lorazepam = Fast Acting

Anxiety Disorders

*Anxiety Disorders* 1.) Panic disorder 2.) Agoraphobia 3.) Generalized anxiety disorder 4.) Social anxiety disorder 5.) Specific phobia *Anxiety Related Disorders* 6.) Obsessive-Compulsive Disorder (OCD) 7.) Post-Traumatic Stress Disorder

Agoraphobia: Pearl

*Associated with, but not always accompanied by, panic attacks—can be a stand-alone diagnosis or found comorbid with panic d/o*

Specific phobia

*Classic type of phobia related to something in particular—an object or situation* - there are subtypes listed in DSM5 including animal, natural environment, bloodinjection-injury, situational, and "other" to reflect the range of categories of phobic stimuli - *Relatively common, w/ estimates of lifetime prevalence in the range of 7.7-12.5%* - F: M ratio: 2:1 - Relatively early in life. - Often very responsive to therapy when tx is sought

Anxiety Disorder: Key Points/Facts

*Consider medical causes* (e.g. hyperthyroid, cardiac problems), substance use (e.g. caffeine overuse) or withdrawal (e.g. from alcohol), and the effects of prescribed medications (e.g., stimulants for ADD). - *Functional impairment* (at school, work, relationships) required to diagnose anxiety disorder - Very responsive to treatment once recognized, often combining meds (antidepressants—SSRIs; buspirone; benzodiazepines for short term use due to risk of dependence/misuse) and therapy (exposure, CBT) - Anxiety disorders very commonly occur along with other psychiatric problems, especially mood disorders and substance use disorders

Benzodiazepines for Other Conditions:

*For treating alcohol withdrawal*: *Chlordiazepoxide* (Librium): Manage ETOH withdrawl, has active metabolites, long half-life *Oxazepam* (Serax): Manage ETOH withdrawl, used less commonly, no active metabolites *For Insomnia*: *Temazepam* (Restoril): Hypnotic, Used for insomnia not anxiety *Midazolam* (i.v. for procedures)

Benzodiazepines: How do they differ from each other?

*Long half-life*: less frequent dosing, less likelihood of troughs with increased symptoms before dose, fewer withdrawal symptoms *Short half-life*: useful as prn's, less accumulation and "hangover" effects; safer in elderly

OCD and PTSD

*OCD and PTSD involve anxiety as a major component, but are considered separately in DSM5 and can be thought of as "anxiety-related disorders"* - There is overlap in these conditions because all involve anxiety; history is the key to making a specific diagnosis - Most require symptoms having been present for a significant period of time (typically, 6mo) - There is a lot of psychiatric comorbidity—especially depressive disorders and substance use disorder (often with alcohol or other CNS depressants) - *Comorbidity with substance use and depression plays a large role in the increase suicide risk in anxiety disorder populations*

Specific phobia: Pearls

*Often causes little functional impairment and doesn't come to clinical attention* (it's not that hard to avoid spiders and continue to function) - but can be problematic (successful in business and need to travel but have severe flying phobia)

Panic Disorder (lecture)

*Recurrent, unexpected panic attacks* *4 or more of*: palpitations, sweating, trembling, shortness of breath, feelings of choking, chest pain, nausea/GI distress, dizziness, chills/heat sensations, paresthesias, derealization/depersonalization, fear of losing control/going crazy, fear of dying *For 1 Month: One or both of*: - Fear of having another panic attack - Significant maladaptive behavior change (e.g. avoidance)

Pharmacologic treatment of anxiety disorders

*SSRI antidepressants are First-line treatment* for: - Panic disorder - Generalized anxiety disorder (GAD) - Social anxiety disorder - Obsessive-compulsive disorder (OCD) - Post-traumatic stress disorder (PTSD) *Buspirone* for GAD *Benzodiazepines* (can be very helpful, in selected situations)

BZD: Tolerance, dependence, withdrawal

*Tolerance*: Needing higher doses to achieve same effect *Dependence*: Physiological and/or psychological *Withdrawal*: Characteristic symptoms when drug withdrawn

Post-traumatic stress disorder (PTSD): Pearls

- *Cannot diagnose PTSD until more than one month since the TE. The disorder is diagnosed as acute stress disorder if less than 1 month* - PTSD is one of the most complex of disorders partly because with the wide array of symptoms, there is a large amount of heterogeneity in clinical presentation

Panic Disorders: Epidemiology

- *F/M ratio: 2.5* - Prevalence 2-3% - *Frequent in cardiac-negative coronary artery disease (CAD) workups* - *Associated with mitral valve prolapse (MVP) and joint hypermobility*

Obsessive-Compulsive Disorder (OCD): Treatment

- *Psychopharmacology (SSRIs or clomipramine (serotonergic TCA), at higher doses than for depression) and psychotherapy (exposure and response prevention)* - Response often takes months rather than weeks as in depression

Panic Disorders: Treatment

- *Psychopharmacology (antidepressants (SSRIs), short-term benzodiazepines)* - *Psychotherapy, (cognitive behavioral therapy (CBT))*

Social Anxiety Disorder: Epidemiology and Course

- *Relatively common, estimated lifetime prevalence: 5-12%* - *F=M rates* - Often starts at a relatively young age, before adulthood. Develops slowly, seldom any precipitating events; chronic course

Post-traumatic stress disorder (PTSD): Epidemiology and Course/Prognosis

- 1yr prevalence estimated 3.5% in US - There appears to be considerable variability in rates in different countries and cultures - *Highest rates have been found in those experiencing military trauma or sexual assault, in particular* - The course can be chronic with significant disability and functional impairment - Protective factors are an area of active investigation

Buspirone

- 5HT-1A partial agonist - *Delayed onset of action (2-4 weeks)* - May be more effective for cognitive anxiety symptoms (worry) - Non-sedating - *No evidence of tolerance/withdrawal* - Side effects - nausea, dizziness, headaches - Does not treat benzodiazepine withdrawal

Generalized Anxiety Disorder (GAD): *Treatment*

- Antidepressants and buspirone - Therapy (CBT, relaxation training, stress reduction)

Benzodiazepine withdrawal symptoms

- Anxiety - Tremulousness - Restlessness - Sweating - Weakness - Hyperreflexia - Perceptual distortions - Seizures - Delirium (hallucinations, delusions, mania)

What are more specific indications for BZD?

- Anxiety disorders - Agitation - Adjunct for psychosis, mania, depression - Insomnia - Muscle relaxation - Anesthesia - Seizure disorders

Specific phobia: Treatment

- Behavioral therapies including exposure and flooding - Medications are not generally effective

Panic Disorders: Course and Prognosis

- Chronic but fluctuating course - Typically begins in early 20s, most have developed panic disorder by age 30

Obsessive-Compulsive Disorder (OCD): Pearls

- Differential dx with delusions: the *O/C are "ego-dystonic"—they are unwelcome, intrusive and attempts are made to resist them, and, there is usually insight into this, both unlike what is usually found with delusions in schizophrenia* - *Do not confuse OCD with OCPD (obsessive-compulsive personality disorder - where one is preoccupied with perfection, organization, etc). OCPD is "ego-syntonic" - pt is not typically aware of or distressed by traits* - OCD and tics commonly co-occur

Social Anxiety Disorder: Pearls

- Formerly known as social phobia - Distinct from specific phobia - There is a specifier (subform) noted in DSM 5 for social anxiety disorder that occurs only in speaking or performing in public

Agoraphobia: Epidemiology (Syllabus)

- Lifetime prevalence of agoraphobia with panic disorder: 1.1% - Agoraphobia alone (without panic disorder): 0.8% - Not good data on M/F ratio of agoraphobia alone.

Social Anxiety Disorder: Treatment

- Medications useful (antidepressants including SSRIs) - *Propranolol (beta blocker) only useful to manage autonomic symptoms associated with performance (e.g., giving a talk), not for chronic tx.*

When would you use a BZD?

- Need for rapid, short-term treatment of anxiety/agitation - Marked functional impairment - Nothing else works - Patient cannot tolerate side effects of other medications - Adjunct early in treatment

Panic Disorders: Pearls

- Often mistaken for a primary medical disorder especially in ED settings (due to cardiac/respiratory-like symptoms), and there is increased use of medical services overall, particularly prior to diagnosis of panic d/o - Can occur with or without a stimulus or trigger to bring a panic attack on - *Take care to r/o medical causes (hyperthyroidism, supraventricular tachycardia, cardiac disease, pheochromocytoma)*

Agoraphobia: Course and Prognosis

- Onset usually around age 20 - Without treatment, the course is often prolonged and chronic and does not tend to remit spontaneously

Obsessive-Compulsive Disorder (OCD): Epidemiology and Course

- Prevalence estimated at 1% - *M=F* - Associated with Tourette's, tic disorders - Onset around age 20, but can occur much earlier, with up to 25% by age 14 - Generally there is a chronic course, with waxing and waning

Generalized Anxiety Disorder (GAD): Course and Epidemiology

- Prevalence: 4-7% - F>M - Peak onset early 20s - Chronic and fluctuating course, often life long, if not treated

BZD: Contraindications

- Respiratory disease (e.g. COPD) - Sleep apnea - Prescribed use of other sedatives (additive effects) - History of substance use disorder (complex issue)

Generalized Anxiety Disorder (GAD): Pearls

- Sometimes described as "free-floating" anxiety - Can be helpful to advise pts to avoid caffeine as much as possible - Patients often self-refer to medical specialists (e.g. for muscle tension) - Elevated frequency of comorbidity with depression, substance abuse

Post-traumatic stress disorder (PTSD)

- Specific kinds of events or experiences are required as qualifying traumas leading to a more prolonged experience of a wide range of symptoms that fall into four clusters - There is a significant amount of heterogeneity of presentation because of the range of potential symptoms - *Acute-stress disorder is diagnosed when symptoms of PTSD are present for <1 month. If symptoms are present greater than 1 month, then PTSD is diagnosed*

Agoraphobia: Treatment

- When co-occurring with panic disorder, generally treated like panic disorder - More specifically for agoraphobia, exposure therapy is helpful, but can require the presence of the therapist "in the field" with the pt to accomplish this

PTSD (lecture)

1.) Exposure to traumatic event 2.) Intrusive symptoms - Memories, nightmares, flashbacks, distress or physiological reactions to triggers/cues 3.) Avoidance - Avoidance of cues, reminders, memories 4.) Cognitive and mood symptoms - Amnesia, self-blame, negative beliefs about the world, diminished interest, detachment, inability to experience positive emotions, fear/horror /anger/guilt/shame 5.) Hyperarousal/increased reactivity 6.) More than one month

Case 8: A 40 year old Caucasian minister comes in complaining of constant anxiety and worry, insomnia, stomach aches, headaches, and irritability for the past year. He realizes that his worries are irrational. On further questioning, he tells you that he has a poor appetite, doesn't enjoy anything, and lacks energy or motivation. He feels he is a drain on his family and that they would be better off without him. When you ask him about suicidal thoughts, he becomes tearful and says that his father was depressed and killed himself when the patient was 10. He has always feared becoming depressed like his father. *What is the most important thing to explore further with this patient?* 1.) Depression 2.) GAD 3.) PTSD 4.) Panic attacks 5.) Suicidal thoughts

...

DSM 5 - Diagnostic Criteria for Agoraphobia

A.) *Marked fear or anxiety about 2 or more of following: - Using public transportation - Being in open spaces - Being in enclosed places - Standing in line or being in a crowd - Being outside of the home alone. B.) The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly, fear of incontinence) C.) Agoraphobic situations almost always provoke fear or anxiety D.) Agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. E.) Fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context F.) Fear, anxiety or avoidance is persistent, typically lasting 6mo or more G.) Fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning H.) If another medical condition (e.g. IBD, Parkinson's disease) is present, the fear, anxiety, or avoidance is clearly excessive I.) Fear, anxiety, or avoidance NOT better explained by the symptoms of another mental disorder *Note*: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual's presentation meets criteria for panic disorder and agoraphobia, both can be diagnosed.

DSM 5 - Diagnostic Criteria for Social Anxiety Disorder

A.) *Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others.* B.) Fears that he/she will act in a way or show anxiety symptoms that will be humiliating or embarrassing, will lead to rejection or offend others C.) Social situations almost always provoke fear or anxiety D.) *Social situations are avoided or endured with intense fear or anxiety* E.) Fear or anxiety is out of proportion F.) *Fear, anxiety, or avoidance is persistent, typically lasting 6 months or more* G.) Fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning H.) NOT attributable to physiologic effects of a substance, or another medical condition I.) NOT better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder J.) If another medical condition (e.g., Parkinson's disease, obesity, disfigurement from burns or injury) is present, the fear anxiety, or avoidance is clearly unrelated or is excessive

DSM 5 - Diagnostic Criteria for GAD

A.) Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6mo, about a number of events or activities (such as work or school performance) B.) Pt finds it difficult to control the worry C.) The anxiety and worry are associated with 3 (or more) of the following 6 symptoms (with at least some symptoms having been present for more days than not for the past 6mo): 1. Restlessness or 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 (difficulty falling/staying asleep, restless, unsatisfying sleep) D.) The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E.) NOT attributable to the effects of a substance or another medical condition F.) NOT better explained by another mental disorder

DSM 5 - Diagnostic Criteria for PTSD

A.) Exposure to actual or threatened death, serious injury, or sexual violence B.) Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the Traumatic Event (TE) occurred C.) Persistent avoidance of stimuli associated with the TE, beginning after the traumatic event occurred D.) Negative alterations in cognitions and mood associated with the TE, beginning or worsening after the TE occurred E.) Marked alterations in arousal and reactivity associated with the TE, beginning or worsening after the TE occurred F.) Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month G.) The disturbance causes clinically significant distress or impairment in social, occupational, or other imporant areas of functioning h.) NOT attributable to the physiological effects of a substance or another medical condition

DSM 5 - Diagnostic Criteria for Specific Phobia

A.) Marked fear or anxiety about a specific object or situation B.) Phobic object/situation almost always provokes immediate fear or anxiety C.) Phobic object/situation is actively avoided or endured with intense fear or anxiety D.) Fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context E.) Fear, anxiety, or avoidance is persistent, typically lasting for 6mo or more F.) Fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning G.) NOT better explained by the symptoms of another mental disorder

DSM 5 - Diagnostic Criteria for OCD

A.) Presence of *obsessions, compulsions, or both* B.) Obsessions or compulsions are time-consuming (e.g. *take more than 1 hour per day*) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning C.) Symptoms NOT attributable to the physiological effects of a substance or another medical condition D.) NOT better explained by symptoms of another mental disorder

DSM 5 - Diagnostic Criteria for Panic disorder (Syllabus)

A.) Recurrent unexpected *panic attacks* [Culture-specific symptoms (e.g. tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen, but do not count of one of the 4 required panic attack symptoms] B.) At least 1 of the attacks has been followed by *1mo (or more) of one or both of*: - *Persistent concern or worry* about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy") - *significant maladaptive change in behavior* related to the attacks (e.g. behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations). C.) *Disturbance not attributable to physiological effects of a substance or another medical condition* D.) Disturbance Not explained by another mental disorder

Agoraphobia

An anxiety disorder where the focus is on being in situations where escape or getting help may be difficult or impossible NOTE: Agoraphobia is no longer a modifier for panic disorder in the DSM 5

DSM 5 - Diagnostic Criteria for OCD: Compulsions

Compulsions are defined by (1) and (2) 1.) Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2.) The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation, but are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

Generalized Anxiety Disorder (GAD) (lecture)

Excessive worry about life circumstances for 6 months or more that is functionally impairing, but not marked by panic attacks - Worry is difficult to control Associated w/ *3 or more*: - Restlessness/being keyed up/feeling on edge - Easily fatigued - Trouble concentrating/mind going blank - Irritability - Muscle tension - Sleep disturbance *Worry causes significant distress/impairment*

Social anxiety disorder

Fear or anxiety in one or more situations when exposed to possible scrutiny by others. - Fear/anxiety about one or more social situations - Fear of negative evaluation - Social situations are avoided or endured with intense fear/anxiety - Persistent (6 months or more) - Significant distress/impairment

Case 12: You have diagnosed panic disorder in a 34 year old woman with a similar presentation as the last case. In addition to a similar clinical situation, this patient reports a history of alcohol use—but only in the past, more than ten years ago, when she was in college in a sorority. It was a brief time but with fairly heavy drinking, including some black outs and one near-DUI episode. She now drinks much less, about 2-3 drinks/week, but does admit to drinking to relieve anxiety at times. She also notes, "I saw a counselor at school and she really helped me talk about stress and get things back on track, I was surprised talking to someone could help so much." Like the last patient, she has been having acute panic attacks and is in a stressful situation at work, which is expected to end in about four weeks. *Question: Would you prescribe a BZD?*

NO - alcohol abuse!

Obsessive-Compulsive Disorder (OCD)

OCD consists of having obsessions and compulsions that are unwanted by the patient and take up substantial amounts of time and effort - Can produce considerable amounts of distress and morbidity - Although now listed in its own chapter in DSM5, it is closely related to other anxiety disorders and anxiety is a very prominent feature in its clinical presentation *Obsessions* - Recurrent, persistent, intrusive, unwanted thoughts - Attempts to ignore/suppress/neutralize them *Compulsions* - Repetitive behaviors - Driven to perform, reduce anxiety/distress, neutralize obsessions - More than one hour/day; cause significant distress/impairment

DSM 5 - Diagnostic Criteria for OCD: Obsessions

Obsessions are defined by (1) and (2) 1.) Recurrent and persistent thoughts, urges or images that are experienced as intrusive and unwanted, and that in most individuals cause marked anxiety and distress. 2.) The individual attempts to ignore or suppress such thoughts, urges, or images, or neutralize them with another thought or action (e.g. performing a compulsion).

Panic Attacks and Panic Disorder: Overview (Syllabus)

Panic disorder involves having panic attacks and anxiety around having additional panic attacks. Panic attacks can occur in many disorders, not only in panic disorder. However, to have panic disorder, you must have panic attacks.

Case 6: A 61 year old male Hispanic physician consults you for a 6-month history of obsessions and rituals. He has constant worries about germs and becoming contaminated. He also finds himself obsessed by order, making sure his belongings are arranged symmetrically and in a particular order. He spends hours each day washing his hands and arranging and rearranging his belongings. His wife is very worried about him. *What would you most want to rule out in this case?* 1.) An underlying medical condition 2.) Major depression 3.) A psychotic disorder 4.) A substance use disorder 5.) Tourette's disorder

Peak onset of anxiety disorders is early in life! Onset in older age = assume there is an underlying medical issue rather than an anxiety disorder! *1.) An underlying medical condition*

Anxiety Disorder

anxiety that is excessive, out of proportion, and interfering with social, occupational or other function (according to DSM5, whether anxiety is out of proportion to what should be expected is determined by the examiner or person doing the assessment)

Post-traumatic stress disorder (PTSD): Treatment

There are highly effective, evidence-based psychotherapies for PTSD including *cognitive processing therapy and prolonged exposure therapy*. Psychopharmacology is also of demonstrated efficacy, particularly with antidepressants in general and prazosin for nightmares

Case 11: You have diagnosed panic disorder in a 34 year old man. He has mild HTN that is not being treated with meds currently and no other medical history. He has no history of alcohol abuse or dependence and drinks very sparingly, about once a month, at social occasions only. He reports he uses cannabis from time to time but denies a history of other substance use.He has been having acute panic attacks once or twice a week that are unprovoked though he does report being in a competitive and stressful situation at work, which is expected to improve after a project deadline is passed in four weeks. He meets criteria for both panic attacks and panic disorder and has marked anticipatory anxiety about having another panic attack. *Question: Would you prescribe a BZD?*

Yes, AS needed short term

Panic Attacks

an abrupt surge of intense fear or intense discomfort that reaches a peak w/in minutes *Time-limited (10-20 minute) episodes w/ 4 or more of any of the following panic attack symptoms*. (not broken into 2 categories in DSM5, but helpful to think of these symptoms this way in remembering them): *Physical Panic Symptoms*: - Palpitations/heart racing - Sweating - Trembling/shaking - Shortness of breath/sense of smothering - Chest pain - Nausea - Feeling dizzy or lightheaded - Chills or heat sensations - Paresthesia *Psychological Panic Symptoms*: - Derealization or depersonalization - Fear of losing control or "going crazy" - Fear of dying

Anxiety

subjective state of worry or fear and is part of normal experiences

DSM 5 - Diagnostic Criteria for PTSD *D.) Negative alterations in cognitions and mood associated with the TE, beginning or worsening after the TE occurred, as evidenced by two (or more) of the following:*

• *Inability to remember an important aspect of the TE* (typically due to dissociative amnesia and not to other factors such as head injury, alcohol or drugs) • *Persistent and exaggerated negative beliefs or expectations* about oneself, others, or the world (e.g., "I am bad," "no one can be trusted," "The world is completely dangerous," "My whole nervous system is permanently ruined"). • Persistent, *distorted cognitions about the cause or consequences of the TE that lead the individual to blame himself/herself or others*. • Persistent *negative emotional state* (e.g., fear, horror, anger, guilt or shame) • Markedly *diminished interest or participation in significant activities* • Feelings of *detachment or estrangement* from others. • Persistent *inability to experience positive emotions* (e.g., inability to experience happiness, satisfaction, or loving feelings).

DSM 5 - Diagnostic Criteria for PTSD *C.) Persistent avoidance of stimuli associated with the TE, beginning after the traumatic event occurred, as evidenced by one or both of the following*

• Avoidance of or efforts to *avoid distressing memories, thoughts, or feelings* about or closely associated with the TE • Avoidance of or efforts to *avoid external reminders* (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the TE

DSM 5 - Diagnostic Criteria for PTSD *A.) Exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways*:

• Directly experiencing the TE • Witnessing, in person, the event as it occurred to others • Learning that the traumatic event occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event must have been violent or accidental. • Experiencing repeated or extreme exposure to aversive details of the TE

DSM 5 - Diagnostic Criteria for PTSD *E.) Marked alterations in arousal and reactivity associated with the TE, beginning or worsening after the TE occurred, as evidenced by two (or more) of the following:*

• Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects • Reckless or self-destructive behavior • Hypervigilance • Exaggerated startle response • Problems with concentration • Sleep disturbance (e.g.., difficulty falling or staying asleep or restless sleep).

DSM 5 - Diagnostic Criteria for PTSD *B.) Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the TE occurred*:

• Recurrent, involuntary, and intrusive distressing memories of the TE • Recurrent distressing dreams (nightmares) in which the content and/or affect of the dream are related to the TE • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the TE is recurring • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the event. • Marked psychological reactions to internal or external cues that symbolize or resemble an aspect of the TE