Psych - Anxiety Disorders

Vulnerability factors for panic disorder include:

genetics, temperament, childhood adversity (e.g. physical or sexual abuse), life stress, and neurobiology

Anxiety Disorders: Treatment of GAD Buspirone: Patients with more severe symptoms, panic disorder, or comorbid depression are best treated with __________

antidepressants

Neurotransmitters Systems in Psychiatric Disorders Benzos: _____ and _________ have no active metabolites and half-lives (mean elimination times) of 12 and 10 hours respectively.

Lorazepam (Ativan) and Oxazepam (Serax)

Antidepressants as anxiolytics: dosing recommendations?

"Start low and go slow" - Slow increases minimize exacerbation of anxiety symptoms - Sertraline (Zoloft) 25 mg qd - Venlafaxine (Effexor) 37.5 mg qd - Final doses are similar to those used in the treatment of major depression

A specifier for major depressive episode or persistent depressive disorder (dysthymia) is

"with anxious distress" (in DSM-V)

When managing a patient with depression and anxiety, which do you treat first?

, first treat the depression, since anxiety often improves with treatment of depression.

Anxiety: epidemiology features

- Anxiety disorders are among the most common mental health problems in the U.S. - 18% of adults in any given year - 28.8% of adults at some point during their lifetime

Anxiety Disorders: Treatment of GAD Benzos: avoid in what patients?

- Avoid BZD in patients with h/o BZD, alcohol, or other substance abuse (unless using to manage withdrawal syndrome) - Avoid in patients with respiratory diseases - DOCUMENT risks of use discussed with patient!

Anxiety Disorders: Treatment of GAD List of anxiolytics (5)

- Benzodiazepines - Selective serotonin uptake inhibitors (SSRIs) - Selective norepinephrine uptake inhibitors (SNRIs) - Tricyclic antidepressants. (TCAs) - Buspirone (occasionally effective for relatively milder forms of GAD)

Neurotransmitters Systems in Psychiatric Disorders Benzos: common SEs? In older patients?

- Can cause anterograde amnesia - Worsen cognitive impairment in elderly - Contribute to falls (incoordination and muscle weakness) - Older patients and patients with decreased liver function, benzodiazepines with very long half-lives and active metabolites (e.g. diazepam [Valium] and chlordiazepoxide [Librium]) should be avoided due to the potential for excess drug accumulation

Anxiety becomes pathological based on the following: (4)

- Excessiveness - Intensity - Duration or chronicity - Impairment

GAD:When choosing a type of treatment, consider: (5)

- Severity of symptoms - Psychiatric and other comorbidities - History of previous pharmacologic therapy - History of drug allergies and other adverse reactions - Patient's readiness to comply with therapy

Neurotransmitters Systems in Psychiatric Disorders Benzos: Lorazepam (Ativan) dosing for panic symptoms or anxiety?

Lorazepam 0.5 mg three times a day (increasing to 1 mg three times a day) is usually effective for panic symptoms or severe anxiety

Screening for anxiety using the GAD-7 shows the problems facing the PCP in diagnosing psychiatric disorders: what are these problems?

- The gold standard in psychiatric diagnosis is the psychiatric interview - However, many PCPs treat many cases of depression and GAD without the interview - Instead, they rely on lists of questions originally devised as screening instruments

Panic disorder (PD) epidemiological factors: most common in what population? Peak occurrence ages?

- Twice as common in women as men - Bimodal distribution in prevalence by age with one peak in late adolescence (15-19 yrs old) and a second peak at later ages (35-50 yrs old) - Patients who develop panic disorder in adolescence frequently develop depressive disorders during early adult years - 1/3 to 1/2 of patients with panic disorder also meet the criteria for major depression at presentation - 60% of patients with panic disorder will have ≥1 lifetime episode of major depression

Patients often have difficulty accurately describing the experience of _______

- anxiety. (e.g. anxiety-disordered patients may report a diffuse feeling of uneasiness or describe feeling "not right" in their body, and then think that something is physically (not psychologically) wrong with them.) - Also, many symptoms of panic attacks (e.g., shortness of breath, chest pain, and dizziness) are among the most common complaints of any patients seeking treatment at medical settings

Anxiety Disorders: Treatment of GAD ________, _________, and _________ may be more efficacious and better tolerated than venlafaxine (Effexor) and paroxetine (Paxil)

- duloxetine (Cymbalta), escitalopram (Lexapro) and pregabalin may be more efficacious and better tolerated than venlafaxine (Effexor) and paroxetine (Paxil)

Criteria for referral to psychiatry for the treatment of GAD are similar to criteria for referral for major depression. This criteria is: (5)

1) Comorbid depression refractory to treatment 2) Psychosis 3) Personality disorders which make treatment for GAD difficult or unfeasible 4) Sensitivity or adverse reaction to multiple medication classes 5) Active suicidal ideation

Risk factors for generalized anxiety disorder include: (3)

1) Female gender 2) Older age 3) Positive family history - Higher prevalence of chronic medical illness (e.g., chronic lung disease, diabetes, heart disease, hypertension, and arthritis) is greater among those with anxiety

List of anxiety disorders: (6 major categories)

1) Panic disorder (PD) 2) Generalized anxiety disorder (GAD) 3) Social anxiety disorder (SAD) or social phobia 4) Agoraphobia 5) DSM-IV anxiety disorders include post-traumatic stress disorder (PTSD), acute stress disorder, and obsessive-compulsive disorder (OCD) 6) DSM-5 PTSD, acute stress disorder, and OCD are in separate categories - Trauma and Stressor Related Disorders: PTSD and acute stress disorder - Obsessive-Compulsive and Related Disorders

When you evaluate someone with potential GAD, there are two issues to consider before making the diagnosis of anxiety

1. Does this patient have a medical disorder whose symptoms overlap with GAD? 2. Does this patient have another psychiatric disorder (e.g., depression)?

Antidepressants as anxiolytics Onset of relief? Side effect profile?

2-4 week delay before symptomatic relief begins Also as with treating depression, side effects are common (including jitteriness, diarrhea, and sexual dysfunction) Side effects often occurring before therapeutic benefit, making adherence to medication difficult

Neurotransmitters Systems in Psychiatric Disorders Benzos: In general, all patients should have benzodiazepines tapered slowly after __________ weeks

3-6 weeks (anxiolytic effects of the antidepressant should have kicked in) Taper benzodiazepines over several weeks

The lifetime prevalence of GAD in American adults is _____%

5%, with twelve-month prevalence of 2-3%

Criteria for panic attacks:

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes: (see image)

Anxiety Disorders: Treatment of GAD Buspirone: advantages?

Advantages are minimal sedative effects and no potential for abuse or dependence This medication does not produce euphoria

Neurotransmitters Systems in Psychiatric Disorders ________, ________, and ________ bind to GABAa receptors, making those receptors more sensitive to GABA

Alcohol, barbiturates, and benzodiazepines Chronic action of alcohol, barbiturates, and benzodiazepines on GABAa receptors *may underlie clinical tolerance and withdrawal*

Neurotransmitters Systems in Psychiatric Disorders Benzos: all patients should be warned of?

All patients should be warned about sedation, addiction potential, effects on driving, and withdrawal with sudden discontinuation

Anxiety Disorders: Treatment of GAD Benzos: Why is alprazolam so potent?

Alprazolam is one of the most potent BZDs It is also very lipophilic (i.e. fat soluble) - which is a big factor in how quickly a medication can get into the brain Since the brain largely consists of fat, a lipophilic drug will get into the brain faster This makes for a quick onset and a quick fall off (like a switch)

Buspirone (Buspar) is in the _____ drug class

Azapirones

Neurotransmitters Systems in Psychiatric Disorders _________ act by enhancing GABA actions

Benzodiazepines

Anxiety Disorders: Treatment of GAD Treat with ___________ until clinical effectiveness of SSRIs can pose a problem in patients with acute anxiety.

Benzodiazepines Benzodiazepines (BZDs) are often used as short term control of anxiety until the effects of the antidepressant kick in.

Anxiety Disorders: Treatment of GAD Why are benzos often considered as short term tx for anxiety?

Benzodiazepines (BZDs) are often considered as short-term treatment for anxiety given their relatively short time of onset (ranging from about ½ to 1 hour) and effective duration (from about 5 to 15 hours).

Social anxiety disorder (SAD) or social phobia Pharm treatment?

Beta-blockers for performance anxiety (e.g. public speaking) (propanolol [Inderal] 10-80 mg /day, atenolol [Tenormin] 50-150 mg/d 1-2 hours before a performance - Blunt/block the physiological symptoms such as tachycardia and tremor

Anxiety Disorders: Treatment of GAD Buspirone: dosing?

Buspirone 5 mg three times a day is starting dose with slow increase up to 20 mg three times a day if needed

GAD can have a chronic course, but...

But maybe not for a large percentage of patients - in a primary care population, the incidence of recovery at 2 years was 40%

Generalized Anxiety Disorder (GAD): Course of illness =

Can be episodic with periods of feeling relatively well Can have a chronic course with fluctuating severity Comorbid GAD and major depression have a worse prognosis

Social anxiety disorder (SAD) or social phobia Characterized by?

Characterized by a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others People with SAD fear they will act in a way or show anxiety symptoms that will be embarrassing or humiliating, or may result in a negative evaluation by others The feared social interaction or performance situations are avoided or endured with intense distress and anxiety

Anxiety Disorders: Treatment of GAD Benzos: ____________ can be useful in tapering patients from BZDs with _____ half-lives

Clonazepam short half-lives (minimizes drug levels fluctuations which could exacerbate withdrawal symptoms)

Cognitive manifestations of anxiety =

Cognitive: worry, apprehension, thoughts of feeling threatened

Generalized Anxiety Disorder (GAD) =

Common and chronic illness characterized by persistent, excessive, and difficult to control worry and tension about life events and daily activities Common worries are about health, finances, work or school relationships, and the health/safety of loved ones

Social anxiety disorder (SAD) or social phobia Commonly feared or avoided situations?

Commonly feared or avoided situations may include attending parties or social gatherings, meeting new people, initiating or maintaining conversations (especially in groups), being the center of attention, speaking in public, and eating or drinking in public - Patients may have panic attacks in these situations

Buspirone: disadvantages?

Disadvantgaes include slow onset; significant adverse effects including dizziness, drowsiness, and nausea; and lack of effectiveness in treating cormorbid psychiatric conditions - Anxiolytic effect may not be achieved for 6 weeks

Panic Attack definition =

Discrete episodes of intense fear that begin abruptly and last for several minutes to an hour - Usually accompanied by autonomic symptoms - Patients commonly present to the emergency room - Can occur in any number of anxiety disorders

Emotional manifestations of anxiety =

Emotional: feelings of uneasiness, edginess, terror

Treatment of GAD: if depression is present?

Evaluate the severity of any coexisting depression, any current or past pharmacotherapy, psychiatric or psychotherapeutic treatment, hospitalizations, and social support Refer to psychiatry patients with severe depression that has been refractory to treatment in the past Refer to psychiatry patients with severe depression that is currently uncontrolled or insufficiently treated Depression and anxiety is commonly found together and can sometimes be treated successfully by a PCP without referral to psychiatrist

Neurotransmitters Systems in Psychiatric Disorders Which system does this describe: - Major inhibitory transmitter in the CNS - One of the key neurotransmitters involved in anxiety and in the anxiolytic action of many drugs used to treat various anxiety disorders

GABA (γ-aminobutyric acid)

_______ is also associated with being divorced or separated; black, Latino, and Asian patients have a decreased risk of _____

GAD (both blanks)

_________ and __________ are common in patients with other psychiatric disorders (e.g., depression, bipolar disorder, and psychotic disorders)

Generalized anxiety and worry These patients are usually not diagnosed with a separate anxiety disorder if the worry occurs only during episodes of illness.

Neurotransmitters Systems in Psychiatric Disorders Benzos: Potent _________ properties and are rapidly effective for severe ________

anxiolytic anxiety

Among other major neurotransmitter systems in the brain with psychiatric relevance are the amino acid systems: (2)

Glutamate GABA (γ-aminobutyric acid)

Neurotransmitters Systems in Psychiatric Disorders Benzos: Why is goal setting (i.e. setting clear expectations about treatment) important?

Goal setting with the patient is important, clearly communicating that benzodiazepines are meant as only short-term treatment until long-term pharmacotherapy has had the chance to work.

In cases of severe anxiety, what is often the most effective treatment?

In cases of severe anxiety, medication treatment for acute anxiety and referral to a psychiatrist may be most effective As with all psychiatric diagnoses, the severity of anxiety is reflected in the degree of distress or impairment in level of functioning (e.g., social, occupational) GAD-7 score is used as an indicator of severity but is not generally used to monitor treatment

Treatment of GAD: Is there a significant risk of suicide?

Independent risk for suicide attempt in patients with anxiety Assess factors that can modify suicide risk (e.g., substance abuse, previous attempts, social supports) Urgent psychiatric referral is required for patients with active suicidal ideation

Anxiety Disorders: Treatment of GAD Benzos: _________________ are recommended on the theory that their half-life (18-40 hrs) confers more stable effects and facilitates tapering

Longer acting agents of high potency (e.g., clonazepam [Klonopin])

Specific Phobia =

Marked fear or anxiety about a specific object or situation (e.g. flying, heights, animals, receiving an injection, seeing blood) The phobic object or situation almost always provokes immediate fear or anxiety The phobic object is actively avoided or endured with intense fear or anxiety The fear or anxiety is out of proportion to the actual danger Lasts 6 months or more

GAD: Deciding between pharmacotherapy and counseling cognitive behavioral therapy vs pharmacologic therapy?

No widely used evidence-based guidelines for using cognitive behavioral therapy vs. pharmacologic therapy. Professional counselor referral for patients with severe depression and anxiety Pharmacotherapy is effective in treating generalized anxiety disorder Providers commonly start with pharmacotherapy and later refer for behavioral therapy if there is a poor clinical response.

Neurotransmitters Systems in Psychiatric Disorders Benzos: dosing for oxazepam (Serax)

Oxazepam 10-15 mg three times a day is usually effective

Agoraphobia refers to?

PD can occur alone or with agoraphobia Agoraphobia refers to marked fear of having a panic attack in certain situations and avoidance of places or situations where escape or obtaining help in the event of a panic attack would be unlikely or difficult

Anxiety Disorders: Treatment of GAD Buspirone (Buspar): Partial agonist of?

Partial 5HT-1A agonist

GAD: screening and diagnosis Patients often present to what setting and with what complaints?

Patients can often present to PCP with non-specific physical complaints and not complaints of "anxiety" Many cases of anxiety go unrecognized and undiagnosed in the primary care setting

Anxiety Disorders: Treatment of GAD Buspirone:possible SEs

Possible side effects are lightheadedness, headache, nausea, restlessness, insomnia, fatigue Generally well tolerated

Panic Disorder defintion

Recurrent, unexpected panic attacks (which are sudden, intense bursts of anxiety or fear accompanied by physical symptoms); persistent worry (≥1 month) about future attacks; and marked levels of distress and/or functional impairment Often results in change of behavior such as agoraphobia, hypochondriacal concerns, and high medical utilization

Social anxiety disorder (SAD) or social phobia Epidemiology (men vs women, age of onset)?

SAD is more common in women than in men Early age of onset, in childhood or adolescence with a chronic, unremitting course

Social anxiety disorder (SAD) or social phobia _______ and _______ are first line therapy for SAD

SSRIs and SNRIs

_____ and ______ are considered first line treatment for GAD. Which drugs specifically?

SSRIs and SNRIs SSRIs - *sertraline and paroxetine* and SNRIs - *venlafaxine* - are effective in treatment of GAD

Anxiety Disorders: Treatment of Panic Disorder Treatment summary points

SSRIs and SNRIs are also used to treat panic disorder Many patients with panic attacks require initial benzodiazepine treatment while waiting for the anxiolytic effects from antidepressants to kick in Initiation of antidepressant medications and use of benzodiazepines is as with GAD Pregabalin has also been seen as effective in panic and social anxiety disorders Cognitive behavioral therapy (CBT) alone or in combination with medications is also effective CBT effects can be sustained over time while relapse rates may be higher after discontinuation of medications

Diagnostic criteria for Agoraphobia (DSM-V) Part 1

See image and next question

Generalized Anxiety Disorder (GAD): DSM-5 Diagnostic Criteria Part 1

See image and next question

_______ are second line agents for treatment of GAD. Best tolerated?

TCAs Nortriptyline (Pamelor) is the best tolerated TCA TCAs are only used if the other treatment options have failed

What is the main screening tool used for GAD?

The Generalized Anxiety Disorder 7-question (GAD-7) scale is a screening tool used

Anxiety Disorders: Treatment of GAD Benzos: Why you should avoid prescribing alprazolam (Xanax) even though it is FDA approved for treatment of anxiety and many people take it without problems?

The addictive potential of a benzodiazepine is related to its half-life (the length of time it takes for the person's body to get rid of the medication), potency, and fat solubility

How high does the GAD-7 need to be to say that treatment for anxiety can be considered?

The cutoff might be different for pharmacological treatment versus psychotherapy. One commonly accepted cutoff is a GAD-7 score of 10, representing moderate anxiety. Many PCPs would feel comfortable starting treatment at that point.

Social anxiety disorder (SAD) or social phobia Pharmacotherapy goal?

The goal of pharmacotherapy is to reduce anticipatory anxiety before, and anxiety during social interaction and performance situations

Anxiety Disorders: Treatment of GAD Benzos: What is the half life of alprazolam (Xanax)?

The half-life for alprazolam (Xanax) is short - about 6-20 hrs

Neurotransmitters Systems in Psychiatric Disorders Two major classes of GABA receptors?

Two major classes of GABA receptors - A and B GABAa and GABAb

Treatment of GAD: what has worked before for this patient?

What have they used to reduce symptoms of anxiety in the past These can be used as part of a suggested non-pharmacologic approach to reduce anxiety symptoms. Let any past treatment success guide current therapies chosen Get previous records or information from previous providers to make sure patient has an adequate trial of a medication or class of medications in past before assuming they did not work

GAD (especially if accompanied by depression) is best treated with?

antidepressant meds Randomized, placebo-controlled trials have demonstrated the efficacy of antidepressants in patients with GAD (SSRIs - paroxitine, sertraline, citalopram; SNRIs - venlafaxine and duloxetine (Cymbalta)

Anxiety Disorders: Treatment of GAD Benzos: features of the the alprazolam-GABA system interaction

With alprazolam working like GABA in the brain, the brain makes less GABA. It takes about a week for the brain to stop making it. It then takes a week or more to start making it again when a patient stops taking Xanax

Neurotransmitters Systems in Psychiatric Disorders Benzos: Care should be taken to distinguish between the _______ anxiety state and the _______ anxiety disorder of GAD. Failure to do this can result it what?

acute and chronic Failure to distinguish the two can lead to overprescribing BZDs with attendant adverse effects

Anxiety Disorders: Treatment of GAD Benzos: The quicker the drug works, making the person feel good, the more ________ it becomes

addicting (cause and effect are close in time = reinforcing the habit of taking the drug) Many people then start taking it more and more often, until they are taking it daily Then they start taking another dose as soon as the last dose begins to wear off Before they know it, they're taking multiple doses a day

Anxiety Disorders: Treatment of GAD Buspirone: It has no _________ properties

anticonvulsant

Physical manifestations of anxiety =

autonomic arousal characterized by palpitations, shortness of breath (SOB), muscle tension, dizziness, upset stomach, chest tightness, diaphoresis, and tremors.

Anxiety Disorders: Treatment of GAD Buspirone: It is not cross reactive with ________ and so cannot prevent __________ from them

benzodiazepines withdrawal

For many individuals, the course of panic disorder is _______ and _______, although symptoms may tend to wax and wane over time

chronic and unremitting

GAD treatment: The best available evidence supports ________

cognitive behavioral therapy (CBT) In studies, pharmacotherapy and counseling are equally effective in treatment of GAD (counseling better because no side effects, not pharmacologic, etc) Counseling may have a greater impact than medications on the severity of any co-occurring depression in patients with anxiety NOTE: The overall effectiveness of pharmacotherapy and counseling is the same.

Anxiety Disorders: Treatment of GAD Benzos: benzodiazepine withdrawal at its worst can cause?

delirium, elevated blood pressure, tachycardia, confusion, hallucinations, and seizures

When evaluating an anxious patient, have a high index of suspicion for?

depression, since depression can present with predominantly anxiety symptoms - especially in the elderly (agitation associated with depression can mimic anxiety) Also. patients with Alzheimer's dementia and vascular dementia, and patients after a stroke can have anxiety symptoms

There is a high comorbidity rate of GAD with ______________

depressive disorders

Benzodiazepines with very short ___________ (e.g. alprazolam [Xanax]) should be avoided: Why? (3 reasons)

half lives - Increased potential for abuse - Increased withdrawal symptoms after sustained use - Rebound anxiety may occur when it is discontinued

High levels of anxiety in patients with other psychiatric disorders has been associated with?

higher suicide risk, longer duration of illness, and decreased response to treatment

Behavioral manifestations of anxiety =

in order to decrease or prevent the perceived threat and associated distress; for example avoidance, escape, and safety-seeking behaviors

Neurotransmitters Systems in Psychiatric Disorders The anticonvulsant activity of benzodiazepines and barbiturates is thought to come from?

neural inhibition mediated through the GABAA receptor (GABAA receptors mediate neuronal excitability [i.e. seizures]; clinical anxiety; and sleep)

Anxiety Disorders: Treatment of GAD Benzos: When possible, use __________ medications to manage anxiety

non-benzodiazepine

Anxiety is often a ______ and _______response to stressful situations

normal and beneficial

Panic disorder is associated with increased incidence of __________

suicide attempts - Patients with both anxiety and mood disorders have higher incidence of suicide attempts than patients with mood disorder alone - Pathogenesis of panic disorder involves both underlying vulnerability factors and stressful life events

BIG PROBLEM - Xanax wears off in a few hours, but it takes a week for the brain to get GABA going again...in the meantime: the patient is in ________

withdrawal Withdrawal then feels like a panic attack but worse. So what do patients do? Take another Xanax

Recovery from GAD is associated with?

older age and lack of other psychiatric comorbidities

Anxiety disorders (including social phobia, GAD, PTSD) frequently co-occur with __________

panic disorder

When agoraphobia is present, it represents a more severe form of _________. Outcome?

panic disorder and has a poorer outcome with respect to level of functioning

Neurotransmitters Systems in Psychiatric Disorders GABA-ergic dysfunction may contribute to what disorder?

panic-disorder

Anxiety Disorders: Treatment of GAD Medication augmentation therapy with __________________ for refractory anxiety, found improvement in patients

pregabalin (Lyrica)

Anxiety Disorders: Treatment of Panic Disorder The goal of pharmacotherapy is to _________

prevent panic attacks