Presentation on theme: "An Update on Anxiety Disorders"— Presentation transcript:
1 An Update on Anxiety Disorders in Primary Care, Part 1:Diagnosis, Presentation, & Evidence-Based Psychological InterventionC. Alec Pollard, Ph.D.Professor of Family & Community MedicineSaint Louis UniversityDirector, Anxiety Disorders CenterSaint Louis Behavioral Medicine Institute
2 Most Prevalent Psychiatric Disorders in Medical Settings Anxiety DisordersDepressionAlcohol/Drug AbuseSomatoform DisordersGoldman, Wise, & Brody (1998)
3 Risks of Failure to Identify Anxiety Disorders in Primary Care: Continued psychological deteriorationPsychiatric comorbidityFamily conflict/dysfunctionVulnerability to medical illness, mortalityCosts to society
5 Primary Symptoms of the Major Anxiety Disorders 1. Panic attacks2. Fear/Avoidancea. of panic/symptom attacksb. of social situations/performancec. of other, specific situations4. Obsessions, compulsions5. Worry6. Flashbacks, nightmares, etc.DISORDERPanic Disorder2. Phobiaa. Agoraphobiab. Social Phobiac. Specific Phobia4. Obsessive-Compulsive Disorder5. Generalized Anxiety Disorder6. Posttraumatic Stress Disorder
6 A Note on Mixed Anxiety & Depression Subclinical levels of both disordersCombination = clinical syndromeMore common in primary care
8 Physical Complaints/Conditions Associated with Specific Anxiety Disorders COMPLAINT/CONDITION1. Attacks of nerves, anxiety, etc.2. concern: fainting, loss ofbladder/bowel control,vomiting3. blushing, trembling, sweating4. difficulty urinating, bladderinfection5. chapped, red skin6. actual fainting7. hypertension8. sleep difficulties9. sexual problems10. fatigueCONSIDER1. Panic Disorder w/ Agor.2. Agoraphobia w/o panic3. Social Phobia4. Social Phobia5. OCD6. Blood/Injec/Injur. Phobia7. anxiety8. anxiety, especially GAD9. anxiety10. anxiety
9 Management of Anxiety Disorders in Primary Care Education about the disorder & treatment optionsEducation about local (e.g., support groups, programs?) and national resources:- Anxiety Disorders Association of America (www.adaa.org)- International Obsessive-Compulsive Disorder Foundation(www.ocfoundation.org)- National Center for PTSD (www.ncptsd.va.gov)Crisis intervention when neededProvide treatment in-house or refer to specialty care
10 Evidence-Based Psychosocial Intervention for Anxiety Disorders Cognitive Behavior Therapy- Education about treatment model- Cognitive therapy to address misappraisals of threat- Coping skills- Systematic exposure to feared situations- Family/environmental intervention (as needed)- Relapse preventionFuture Directions- Drugs/behavioral procedures to enhance learning inCBT- Psychological interventions to address treatmentambivalence
11 Advantages & Disadvantages of CBT (vs medication) - takes more effort/time- less accessibleAdvantages:- Fewer side effects- Superior long-term outcome
12 An Update on Anxiety Disorders in Primary Care, Part 2: Pharmacological Treatment Eric Nolan, M.D.Adult PsychiatristChief FellowDivision of Child PsychiatryWashington University in St. Louis
13 A Common Presentation… 36yo female presents to her PCP’s office with the chief complaint of poor concentration and difficulty sleeping for the past several yearsStay at home mother of a 4 year old boy and a 6 month old girlHusband works 60+ hours/week as a laborer when he is able, but work is hard to come by
14 A Common Presentation… On further questioning, you find out that she feels overwhelmed frequently, and “worries about everything”She feels unable to manage the household because she feels “scatterbrained” and is always worried about “what’s going to happen next”
15 A Common Presentation… When you probe further about her sleep, she says that once she falls asleep, she is “perfect”However, it can take up to 2-3 hours for her to do soShe also feels fatigued “most of the day”
16 In the Office… You have identified what you believe to be anxiety You note a moderate amount of impairment—enough to present to a PCP with these symptoms as the primary complaintYou feel that this warrants treatment, but which type—psychotherapy, medication, or both?
18 Fluoxetine (Prozac) First of this group Most well-studied in adults Starting dose of 20mg/day, max 60mg/dayCommon side effects: activation, +/- weight gain, sexual side effectsFDA indications for OCD, Panic DO
19 Sertraline (Zoloft) Second SSRI to obtain approval Starting dose 50mg/day, up to 200mg/dayCommon side effects: sedation, sexual side effects, LESS ACTIVATING than fluoxetineIndicated for treatment of PTSD, OCD, Panic DO, social phobia (social anxiety disorder)
20 Paroxetine (Paxil) Approved around the same time as sertraline Starting dose of 20mg/day, max 60mg/dayMost active serotonin inhibitorleast well-toleratedCommon side effects: sedation, weight gain, sexual side effects, anti-cholinergic side effectsIndicated for treatment of OCD, Panic DO, PTSD, social phobia (social anxiety DO), GAD
21 Citalopram (Celexa)/ Escitalopram (Lexapro) Most recent additions to the SSRI’sStarting doses:Citalopram 20mg/day, max 60mg/dayEscitalopram 10mg/day, max 30mg/dayVery well-tolerated due to less potent activation of 5HT receptorSide effects are uncommonIndicated for treatment of GAD
22 Venlafaxine (Effexor XR) First SNRIStarting dose mg/day, max 300mg dailyCommonly used to treat co-morbid anxiety and depressionEffective for anxiety at HIGHER doses (>150mg/day)Common side effects: dizziness, diaphoresis, headache, monitor for elevations in BPIndicated for treatment of MDD
23 Duloxetine (Cymbalta) Newest SNRIStarting dose 30mg/day, max 120mg/dayCommonly used to treat anxiety associated with pain syndromesCommon side effects: diaphoresis, headaches, insomnia (usually dose-related)Indicated for treatment of GAD, fibromyalgia, chronic musculoskeletal pain
24 Mirtazapine (Remeron)/ Bupropion (Wellbutrin) Not indicated for treatment of anxiety disordersSome retrospective data suggests there may be some utility for bupropion in anxiety disorders, but the data is not sufficient at this time to warrant use as primary pharmcotherapeutic agent
25 Benzodiazepines Act at the GABA-A receptor (same as alcohol) Very effective in the treatment of anxietyHOWEVER: must be very judicious in their useDifferent benzodiazepines carry different sets of riskLong-acting benzodiazepines:Clonazepam (Klonopin), diazepam (Valium)Short-acting benzodiazepines:Lorazepam (Ativan), alprazolam (Xanax)
26 BenzodiazepinesConsider severity of symptoms in deciding whether or not to start a benzodiazepineBenzodiazepines should NEVER be used as monotherapy for treatment of an anxiety disorderMay start at low-dose concurrently with an SSRI, with the goal that as SSRI becomes effective over 4-6 weeks, benzodiazepine may be decreased/discontinued
27 Buspirone (Buspar) 5HT-1A receptor partial agonist Mild anxiolytic Often used with SSRI’s for treatment of mild anxietyEfficacy is debatedStarting dose is 15mg/day, max 60mg/dayNo potential for abuse/dependenceNo common side effectsIndicated in treatment of GAD
28 Children and Elderly: Other Considerations These medications are generally considered safe in children and the elderlyHowever, there is less data to support their useBLACK BOX WARNING for SSRIs/SNRIs in children and adolescentsGeneral rule: “start low, go slow”More susceptible to side effects
29 ConclusionsMany AD sufferers still do not receive evidence-based treatment.Most who do receive evidence-based treatment obtain significant improvement in symptom relief and functioning.Both drug and cognitive behavioral therapies are effective, but each haslimitations and strengths.Combined approach is superior for some patients, especially the more severe.CBT improves long-term outcome and can reduce relapse if initiated during drug discontinuation.
30 Related ReadingsAmerican Psychiatric Association. (1995). Diagnostic and Statistical Manual of Mental Disorders IV: Primary Care Version. Washington DC: APA Press.Kroenke et al. (2007). Anxiety disorders in primary care: Prevalence, impairment, comorbidity, & detection. Annals of Internal Medicine, 146, 317.Stein. M. B. (2003). Attending to anxiety disorders in primary care. Journal of Clinical Psychiatry, 64 (suppl 15), 35.Sullivan et al. (2007). Design of the coordinated anxiety learning and management (CALM) study: Innovations in collaborative care for anxiety disorders. General Hospital Psychiatry, 29, 379.ZoberiK., & Pollard, C.A. (2010). Treating anxiety without SSRIs. Journal of Family Practice, 59, 313.
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